MEDICINE

CNS CASE PROFORMA ANS:

-No H/O Bladder/Bower incontinence
Name: Age: Sex: Occupation: Address: -No H/O excessive sweating
Date and Time of Admission: Date and Time of Examination
Aetiology:
HISTORY 1. -No H/O Head Trauma (for haemorrhagic stroke)
2. -No H/O Epilepsy, if K/C/O epilepsy ask about medications
Chief Complaints:
3. No H/O projectile vomiting, headache or blurring of vision
Inability to use Rt/Lf UL/LL since __ days
4. -No H/O chest pain/ palpitations/ swelling or fleeting pain
Slurring of speech since
of joints/ painful nodules on fingertips (for RHD/IE)
Deviation of mouth towards __side since__days
5. -No H/O bleeding through nose/ gums/ urine’ rectum (for
bleeding disorders)
History of Present Illness: 6. -No H/O recent vaccinations or dog bite (rabies)
Pt was apparently asymptomatic X days ago. Then on __ date 7. -No H/O fever/ sore throat/ ear ache/ ear discharge/
ie on __day __ around __time he went to his neighbour’s nasal discharge
house where he suddenly noticed. 8. –No H/O recent surgeries (for embolic stroke)
9. – No H/O repeated blood transfusions (haemolytic anaemias)
 Inability to use Rt/Lt UL/LL simultaneously with
complete loss of power. Summary:
 Associated with deviation of mouth to __side__ ___ sided hemiplegia with ___ nerve palsy with or without
 Slurring of speech speech involvement with stroke in evaluation.
 Loss of consciousness
Anatomical: Cortical/ internal capsule/ brainstem/ spinal cord/
Then he was taken to nearby hospital and treatment was peripheral nerves/ NMJ/ Myopathies
started. Pathological: Embolic/Thrombus/ Hemorrhagic
Etiological: Vascular/Metabolic/Degenerative
Weakness: ___ onset, uniformly distributed in both UL and
LL, progressive/static/improved, no diurnal variations (To Past History:
differentiate with Rheumatoid Arthritis), not associated with -No H/O similar complaints in the past
wasting of muscles or involuntary movements. Not -No H/O HTN, DM, TB, Hypo/Hyperthyroidism/ Epilepsy/
associated with stiff of muscles. Asthma/COPD/ CAD/ Blood transfusions/ Connective tissue
Not able to lift his hand above shoulders (proximal), unable disorders (stroke in young)
to comb his hair (Proximal + Distal), unable to -No H/O Major hospitalizations
button/unbutton his shirt & unable to mix food (Distal). -No H/O major surgeries
Unable to get up from squatting position (P), Unable to
climb stairs (P+D) and unable to grip his footwear (D). Pt is Family History: None of the patient’s parents, siblings or first degree relatives have
or have had similar complaints or any significant co morbidities
bedridden at present.
Higher Intellectual Functions: Personal History:
-No H/O Loss of consciousness Diet, Appetite, Bowel, Bladder, Sleep
-No H/O Memory loss Addictions- For females ask for OC pills, Smoking is
-No H/O speech abnormality important. Drug addictions- Valvular lesions
-Episode is not associated with seizures
CRANIAL NERVES: Treatment History:
-No H/O Loss of smell
-No H/O abnormality in vision/colour vision/ deviation of
eyes/ doubling of object/
-No H/O Loss of sensation over face, difficulty in chewing
-No H/O Inability to close his eyes, watering from eyes,
deviation of mouth, dribbling of saliva
-No H/O Loss of hearing, tinnitus, vertigo GENERAL EXAMINATION:
-No H/O Hoarseness of voice, difficulty in swallowing
-No H/O Difficulty of turning of head to any side or lifting A __ year old patient, supine decubitus who is __ built __ nourished is
conscious, coherent, cooperative, and comfortably seated/lying on the bed,
head from pillow
well oriented to time, place and person.
-No H/O Deviation of tongue, difficulty in protrusion of There is No Pallor, Icterus, cyanosis, koilonychias, generalised
tongue lymphadenopathy and no pedal edema.

Sensory: -No neurocutaneous markers (phacomatosis)

-No H/O tingling, numbness sensation Ash leaf macules, shagreen patch, café au lait spots, adenoma
sebaceoum, port wine stain
-No H/O loss of sensation of touch, pain
-No Hair loss
-No other history suggestive of any other sensory deficit. -No facial puffiness
-No Subcutaneous nodules, fever- RHD
Cerebellum:
-No Osler nodes- IE
-No H/O loss of coordination, balance, swaying -No Arcus Juvenilis, Tendon Xanthemas- atherosclerosis
-No spina bifida

Syed Murtuza Hashmi, Osmania Medical College

 4. REFLEXES: [For both sides]
Attitude of limbs- for all four limbs must be written.

Vitals: Superficial:
Temperature, Corneal, Conjunctival, Abdominal (T8, T10, T12), Plantar
Pulse Rate: Check Carotid pulse equality. Deep:
BP Biceps, Triceps, Brachioradialis
RR Knees, Ankle
GRADING:
SYSTEMIC EXAMINATION
0+ Absent
1. INTELLECTUAL FUNCTIONS: 1+ Diminished Reflex
1. Handedness 2+ Normal
3+ Exaggerated
2. Memory: Recent and Remote
4+ Clonus
3. Appearance: Well-kept or not
4. Level of consciousness (Can use Glasgow Coma Scale)
5. Speech- fluency, comprehension, repetition, naming 5. SENSORY SYSTEM:
objects, reading, writing, calculation
Superficial: Fine touch, Temperature, Pain
2. CRANIAL NERVES: Deep: Joint, Position,
Nerve Procedure Right Vibration: at all spinous processes, ASIS, tibial tuberosity
and and medial malleolus.
Left Crude touch, Stereognosis, Graphesthesia, 2 point
1. Olfactory Close eyes, close one nostril and discrimination,
repeat on both sides. Use smelling
salt, coffee, asafetida
2. Optic 1. Visual acuity: Snellen/ Counting 6. CEREBELLUM: Speech, Nystagmus, Pendular knee
Fingers from 6m onwards, Hand jerk, Ataxia, Tremors, Released reflexes
Movements close to face, Projection
of light and Perception of light 7. COORDINATION AND GAIT: Finger Nose test, Finger
2. Visual Field: (Confrontation)
3.Colour vision Finger test, Heel knee test, Gait, Romberg test
4. Reflexes- Light and Accom
5. Fundus Exam 8. Skull and Spine,
3,4,6 CN Ocular movements 9. Signs of Meningeal Irritation: Nuchal Rigidity, Kernig’s
Trigeminal Nerve Motor: Pterygoids, Temporalis
(Mastication) and Brudzinski siType equation here. gn.
Sensory: Over face, corneal,
conjunctival reflex, jaw jerk OTHER SYSTEMS:
Facial Nerve Deviation of mouth, frowning, closure of
eyes against resistance, blowing, whistling,
CVS- Check RHD, IE, AF, Embolism
smiling, accumulation of tears, drooling of Respiratory: Broncho Ca,
saliva
Vestibulocochlear Whispering, watch test, rinnes, weber, GIT- HCC
Nerve schwabach
Vagus & Gag reflex, uvula position DIAGNOSIS:
Glossopharyngeal
Spinal Accessory Shrug shoulders, movement of head to one
side against resistance
Hypoglossus Deviation of tongue, See tongue inside the Right/Left sided CerebroVascular Accident with
mouth for fasciculations
left/right sided Hemiplegia with __ cranial nerve palsy,
3. MOTOR SYSTEM: involvement of ___ area supplied by ___ artery due to
A. Attitude and Position embolism/thrombus/haemorrhage.
B. Nutrition (Bulk) - See whole limbs, small muscle
wasting in motor neuron disease. Wasting is measured
in upper limb at 10cm above and below the olecranon
process and for lower limb at 15cm above and below the
tibial tuberosity. LOCALIZATION OF LESION:
C. Tone: Check in antigravity muscles- UL-Bicpes and LL-
Quadriceps. Rolling of muscles over bony prominences. Cortex C/L Hemiplegia, Aphasia if dominant lobe
Increased tone: Rigidity (extrapyramidal) or spasticity lesion
(pyramidal) Internal C/L Hemiplegia, Ipsilateral UMN type 7
Capsule nerve palsy (causing C/L face weakness)
D. Power: See Neck, Truck, UL and LL muscles.
Midbrain C/L Hemiplegia, Ipsilateral UMN 3rd nerve
0 No Power palsy
1 Flicker of movement Pons C/L Hemiplegia, Ipsilateral 6th Nerve- (Lat
2 With elimination of gravity Rectus), Ipsilateral LMN 7th Nerve
3 Against Gravity Medulla C/L Hemiplegia, Ipsilateral LMN 12th
4 Against resistance Nerve (tongue paralysis same side)
5 Normal Spinal Ipsilateral Hemiplegia, No cranial nerves
Cord
E. Abnormal Movements:

Syed Murtuza Hashmi, Osmania Medical College

 CVS CASE PROFORMA and Smoking)
Drug intake: H/O Penicillin prophylaxis once in 3 weeks.
Name: Age: Sex: Occupation: Address:
Date and Time of Admission: Date and Time of Examination GENERAL EXAMINATION

HISTORY A __ year old patient, supine decubitus who is ___ built __

nourished is conscious, coherent, cooperative, and
Chief Complaints:
comfortably seated/lying on the bed, well oriented to time,
Chest pain since __ days
place and person.
Shortness of Breath since __ days
Palpitations since ____ days There is No Pallor, Icterus, cyanosis, koilonychias,
Syncope since ____ days generalised lymphadenopathy and no pedal edema.
(Any other complaints if present) Comment on JVO (Raised or not)

History of Present Illness: Grades of Pedal Edema:

Pt was apparently asymptomatic X days back then he 1: Up to Ankle
developed 2:Up to Knee
1. Chest Pain: ___ duration, site, onset, progress, episodes, 3: Full Leg
type, radiation, aggravating and relieving factors, associated 4: Anasarca
night sweats. [Retrosternal, squeezing, radiating to left hand,
jaw, sometimes to right hand] Peripheral Signs of Aortic Regurgitation:
2. Palpitations: At Rest/ Exertion -Quincke’s sign= cyclic reddening and blanching of nail
Duration, onset (persistent/paroxysmal), progress, regularity capillaries
(rapid, slow), orthopnoea, PND, Aggravating and relieving - Collapsing pulse
factors] -Bisferiens pulse= double systolic arterial impulse- twice
3. Breathlessness: Duration, onset, progress, grade, orthopnoea, beating heart
PND, AF and RF -Water Hammer pulse
Grades of Breathlessness: -Lighthouse sign- flushing of forehead
Grade 1: On extremely sever exercise - Corrigan’s pulse= prominent carotid pulsation
Grade 2: On accustomed work - De Musset’s sign on auscultation= Head nodding with each
Grade 3: On routine activity heart beat
Grade 4: At rest -Traube’s sign= Pistol shot sign of femoral artery
4. Syncope: Onset, exercise auscultation
related/circumstantial/positional/neurological - Duroziez’s murmur on auscultation= Femoral artery bruit
5. Cyanosis: Onset, relieving in squatting position - Hill’s sign BP- accentuated leg SBP >40 mmHg different
6. Pedal Edema: Onset, Unilateral/Bilateral, Progression, grade, wrt Brachial artery SBP
pitting/non-pitting, Af and RF, duration. -Becker’s sign= Pulsating retinal arteries
-Lincoln Sign- Pulsatile popliteal
H/O fatigue -Sherman Sign- Prominent dorsalis pedis
H/O cough, haemoptysis ( MS/ Pulmonary Edema) -Muller’s sign- Uvula pulsations with each heart beat
H/O dysphagia, hoarseness of voice in (LAH due to MS) -Landolfi’s sign- Alternating constriction and dilation of
H/O high arched palate, chest deformity – for congenital dx pupils
H/O recurrent respiratory tract infections, fever, sore throat, -Rosenbach’s sign= Pulsating liver
clubbing, splinter haemorrhages- Infective Endocarditis -Gerhardt’s sign= Pulsating spleen
H/O fever, joint pains- Rheumatic Fever
VITALS: Temperature,
SUMMARY: Pulse: Rate, rhythm(regular/irregular), character(normal or
A __ year old male/female patient presented with ___(positive not), volume ( high, normal, low), blood vessel thickening,
findings). peripheral pulsations [Carotid, brachial, radial, femoral,
Anatomical: popliteal, posterior tibial, dorsalis pedis], radio femoral
Etiological: delay or radio radial delay (present or not)
Pathological: The above mentioned positive history is in favour of GIT
system hence I have examined the GIT system in the ____
PAST HISTORY: position
H/O similar complaints in the past BP: 120/80 mm Hg measured on Rt Upper arm In supine
H/O HTN, DM, TB, Hypo/Hyperthyroidism/ Epilepsy/ position
Asthma/COPD/ CAD/ Blood transfusions Respiratory Rate: Thoraco abdominal in females, Abdomino
thoracic in males
FAMILY HISTORY:
None of the patient’s parents, siblings or first degree relatives have or SYSTEMIC EXAMINATION-CVS
have had similar complaints or any significant co morbidities

PERSONAL HISTORY:
INSPECTION:
Diet, Appetite, Bowel, Bladder, Sleep, Addictions (Alcohol
1. Shape of Chest

Syed Murtuza Hashmi, Osmania Medical College

2. Trachea position central or not Any Foreign sounds
3. Any visible precordial bulge(look from end of the bed) Opening snap
4. Visible apex impulse in Lt 5th ICS medial to Mid clavicular Ejection Click
line
5. Any visible left parasternal pulsation – Rt Vent HTN 2. Tricuspid Area:
6. Visible Epigastric pulsations- Aoritc aneurysm Two heart sounds heard, S1 and S2 which are normal
7. Visible 2nd ICS pulsations- Pulmonary Artrery HTN Murmurs same as Mitral area but in lower intensity
8. No other visible pulsations seen
No other scars, sinuses or dilated veins seen in any part of 3. Aortic Area:
the thorax. Two heart sounds are heard, S1 and S2
No bony abnormalities seen (Spine) No murmurs.

4. Pulmonary Area:
PALPITATION: Two HS heard, S1 and S2.
1- All inspector findings were confirmed. S2 is louder than S1.
2-Trachea is central. 5. Erb’s Area- Neo Aortic Area [ 3rd ICS on Lt side]
3-Apex Beat confirmed to be in Lt 5th ICS 1cm medial to MCL
Note: Tapping in character, Localized, Palpable S1,
Corresponding with Carotid pulse, palpable systolic thrill OTHER SYSTEMS:
4-Any palpable heart sounds, suprasternal pulsations CNS- No facial asymmetry, All reflexes are normal
5- Parasternal heave seen in RVH Respiratory: Normal Vesicular Breath sounds, No
6- Any palpable murmurs (thrills) adventitious sounds heard
7- No venous hum at the base of the neck. GIT- No HSM(hepatosplenomegaly), No Ascites
[Venous hum is a benign phenomenon. At rest, 20% of the cardiac output
flows to the brain via the internal carotid and vertebral arteries. This drains
via the internal jugular veins. The flow of blood can cause the vein walls to
DIAGNOSIS:
vibrate creating a humming noise which can be heard by the subject. It is a case of Chronic RHD with MR/MS with or without
Typically, a peculiar humming sound is heard in the upper chest near the congestive heart failure without sings of infective
clavicle. endocarditis in sinus rhythm.
This may be confused with a heart murmur. The venous hum is heard
throughout the cardiac cycle. The difference is easily detected by placing a
finger on the jugular vein when listening to the heart, which will abolish or
change the noise. A true heart murmur will be unaffected by this manoeuvre.
The murmur also disappears when the patient is in the supine position or may
disappear if the subject turns their head to one side. It is also known by the
names "nun's murmur" and "bruit de diable" (the Devil's noise).]

Levine Scale for grading of murmurs:

Grade 1. The murmur is only audible on listening carefully
for some time.
Grade 2. The murmur is faint but immediately audible on
placing the stethoscope on the chest.
Grade 3: A loud murmur readily audible but with no thrill.[4]
Grade 4. A loud murmur with a thrill.
Grade 5: A loud murmur with a thrill. The murmur is so loud
that it is audible with only the rim of the stethoscope
touching the chest.
Grade 6: A loud murmur with a thrill. The murmur is audible
with the stethoscope not touching the chest but lifted just
off it.

PERCUSSION:
1. Rt border of heart corresponds to Rt sternal border
2. Lt border of heart corresponds to apex beat
3. Pulmonary areas resonant on percussion

AUSCULATION:
1. MITRAL Area:
Two Heart sounds heard. S1 and S2. S1 loud, S2 normal
Murmur:
Type- Mid Diastolic/Pan Systolic etc
Character- Low pitch rumbling etc
Radiation
Best heard in Lt Lateral position with bell of the stethoscope
with breath in expiration
Any presystolic attenuation

Syed Murtuza Hashmi, Osmania Medical College

 GIT CASE PROFORMA GENERAL EXAMINATION

Name: Age: Sex: Occupation: Address: A __ year old patient, supine decubitus who is __ built __
Date and Time of Admission: Date and Time of Examination nourished is conscious, coherent, cooperative, and
HISTORY comfortably seated/lying on the bed, well oriented to time,
place and person.
Chief Complaints:
There is No Pallor, Icterus, cyanosis, koilonychias,
Fullness in the abdomen since __ days
generalised lymphadenopathy and no pedal edema.
Pain in abdomen since __ days
Yellowish discolouration since ____ days
-Signs of liver cell failure:
Alopecia (selective), Hirsutism in females, Gynecomastia in
History of Present Illness: males (Excess estrogen), atrophy of breast, palmar
Pt was apparently asymptomatic X days ago then he noticed
erythema, spider naevi- see in natural light, strip the patient
fullness in the abdomen which was ___ in onset, progressive or
Duptyrens contracture, cachexia, koilonychia, clubbing,
not and has attained present size.
caput medusa, Testicular atrophy, Hepatic Foetor-
Any association with breathlessness, pedal edema (pitting or
characteristic sweet smelling breath
non-pitting), vomitings, diarrhoea,.
-Signs of chronic alcoholism= Parotid swelling, Facial flush,
He also experienced epigastric pain which was __ in onset,
Duptuyrens contracture.
generalised/localized to __ region since __ days, radiation
(present or absent), aggravating and relieving factors, character
- Signs of Hepatic Encephalopathy:
of pain, variations.
Early feature- constructional apraxia (ask patient to draw a
H/O of Hematemesis, Malena, Vomiting, Nausea
star), Asterixis (flapping tremors- patient should be sitting
H/O bulky stools, black tarry, and clay coloured.
position, conscious, should be able to obey command)
H/O Jaundice, pruritus
-Eyes for KF Ring- Wilsons disease
H/O fever with chills
-Child- Alpha 1 anti-trypsin deficiency- has respiratory
H/O anorexia
symptoms
H/O orthopnea, palpitations
-Extrapyramidal type CNS involvement with Jaundice=
H/O platypnea,
Wilsons disease see for KF ring also
H/O frothy urine
-Virchow Lymph nodes (supraclavicular lymph nodes
H/O haematuria, oliguria
enlarged) For malignancy
H/O blood transfusions
H/O tattoo marking H/O involuntary movements PICCKLE
H/O altered sleep, flapping tremors VITALS: Temperature, Pulse, RR, BP
H/O loss of weight, The above mentioned positive history is in favour of GIT
system hence I have examined the GIT system in the ____
SUMMARY: position
A __ year old male/female patient presented with ___ (positive
findings). SYSTEMIC EXAMINATION-GIT
Anatomical:
-Detailed exam of Upper GIT:
Etiological:
Lips, Oral mucosa, gums, gingival hypertrophy(leukaemia
Pathological:
M3 of AML), Blue line on gums- Lead Poisoning, Perioral
PAST HISTORY: papillomatosis in Peutz Jherger and Gardner Syndrome,
No H/O similar complaints in the past Oral candidiasis, fetor Hepaticus, Halitosis
-No H/O HTN, DM, TB, Hypo/Hyperthyroidism/ Epilepsy/ P/A Examination:
Asthma/COPD/ CAD/ Blood transfusions INSPECTION:
9 REGIONS
FAMILY HISTORY: Shape (scaphoid, elliptical, globular)
None of the patient’s parents, siblings or first degree relatives have or Distention of Abdomen ( 6 F’s= Fluid, Foetus, Fat, Faeces,
have had similar complaints or any significant co morbidities Flatulence, Full size tumour)
H/O Maternal Hep B, Vaccinated at birth or no. Flanks- full or not,
Umbilicus- shape, position, herniation, discharge
PERSONAL HISTORY:
Movements with respiration
Diet, Appetite, Bowel, Bladder, Sleep, Addictions (Alcohol and
Skin over abdomen: (smooth, shiny), (pigmentation)
Smoking)
Any engorged veins, visible pulsations, hernia orifices.
Drug intake
PALPITATION:
The CAGE assessment for alcohol dependency
Start from are of least tenderness. Pain in renal angles =
C – Have you ever felt the need to Cut down your alcohol
Pyelonephritis,
consumption?
Superficial: Temperature, Tenderness, Guarding, Rigidity,
A – Have you ever felt Angry at others criticizing your drinking?
palpable masses
G – Do you ever feel Guilty about excess drinking?
Deep: Fluid Thrill with legs extended (If tense ascites, 1.5-
E – Do you ever drink in the mornings (Eye-opener)?
2Litres)
Two or more positive answers could indicate a problem of Milking Test (direction of flow of abnormal veins), Rebound
dependency. tenderness, Visible Peristalsis.

Syed Murtuza Hashmi, Osmania Medical College

Organ Palpation of Liver: edge, extent, consistency, surface,
tenderness, pulsation, movement with respiration, insinuation of Palpation of liver: character of its surface (i.e. whether it is
fingers under costal margins soft, smooth and tender as in heart failure, very firm and
Spleen: palpable or not, mobility, ballotment, fingers insinuation regular as in obstructive jaundice and cirrhosis, or hard,
Gall Bladder: palpable or not irregular, painless and sometimes nodular as in advanced
Measurements: 1. Abdominal girth at the level of umbilicus, 2. secondary carcinoma).
In tricuspid regurgitation, the liver may be felt to pulsate.
Xiphisternum to Umbilicus
Occasionally a congenital variant of the right lobe projects
3. Umbilicus to Pubic symphysis
down lateral to the gallbladder as a tongue-shaped process,
4. Spinoumblical (ASIS to Navel, if both sides not equal think ovarian called Riedel’s lobe.
tumours) Though uncommon, it is important to be aware of this
because it may be mistaken either for the gallbladder
PERCUSSION:
1. Shifting Dullness )(patient has to void urine) itself or for the right kidney.
2. Tidal percussion Child Pugh score to assess the prognosis of chronic liver
Organ Span- Liver span. Less than 9 = Cirrhosis, More than 14= disease.
Hepatomegaly
West Haven Classification of Hepatic Encephalopathy:
AUSCULATION: Stage 1 : Euphoria/Depression, Mild confusion, slurred
1. Bowel Sounds, 2. Splenic Rub 3. Hepatic rub and bruit 4. Venous speech, sleep disturbance
hum (If caput medusa around navel) Stage 2: Lethargy, Moderate confusion
Paralytic Ileus- Absence of bowel sounds Stage 3: Marked confusion, inherent speech, Patient is
arousable from sleep.
OTHER SYSTEMS:
Stage 4: Coma
CVS- Normal S1 S2 heard, No murmurs.
Asterixis is seen only in the first 3 stages. Not seen in 4.
Respiratory: Normal vesicular breath sounds, No adventitious
EEG is normal in stage 1, otherwise abnormal.
sounds
CNS- No Facial asymmetry, all reflexes are normal

DIAGNOSIS:
This is a case of decompensated Chronic liver disease with jaundice
and ascites, with no signs of Hepatic encephalopathy, probably
secondary to chronic alcoholism.

NOTES:
Calculate units of alcohol:
1 unit of alcohol is equivalent to 8 gm (10 ml) of ethanol.
Number of units of alcohol = volume of alcohol (litres) X % alcohol
by volume (ml/100 ml)
Males 21gm/week, Females 14gm/week
1 unit of alcohol = 8gms

1 small glass (125 ml) of wine (8%)

1 half-pint (250 ml) of beer (4%)
1 short (25 ml) of spirits (40%)
Dose of Alcohol causing cirrhosis:
Male- 80-160gm/day for 10-20 years
Female- 40-80gm /day for 10-20 years

Grading of Ascites:
+ Detectable on careful examination
++ easily detectable but of small volume
+++ Obvious ascites but not tense
++++ Tense ascites

Shifting Dullness = 1000m

Fluid Thrill= >2000 ml
Puddle Sign= 120 ml

Courvoisier’s law
This states that in the presence of jaundice, a palpable
gallbladder makes gallstone obstruction of the common bile
duct an unlikely cause (because it is likely that the patient will
have had gallbladder stones for some time and these will have
rendered the wall of the gallbladder relatively fibrotic and
therefore non-distensible). However, the converse is not true,
because the gallbladder is not palpable in many patients who
do turn out to have malignant bile duct obstruction.
Syed Murtuza Hashmi, Osmania Medical College
 RESPIRATORY CASE PROFORMA nourished is conscious, coherent, cooperative, and
comfortably seated/lying on the bed, well oriented to time,
Name: Age: Sex: Occupation: Address: place and person.
Date and Time of Admission: Date and Time of Examination
There is No Pallor, Icterus, cyanosis, koilonychias,
HISTORY generalised lymphadenopathy and no pedal edema.
Chief Complaints: Comment of JVP (hepato jugular reflex)
Cough since __ days
Chest pain since __ days Grades of Clubbing:
Difficulty in respiration (Breathlessness) since __ days 1: Nail bed fluctuations
2: Obliteration of Lovibond angle
History of Present Illness: 3: Parrot beak appearance
Pt was apparently asymptomatic X days back then he 4: Hypertrophic osteoarthropathy
developed
1. Cough: Duration, type, postural variation, seasonal variation, VITALS: Temperature,
syncope, chest soreness, bowel-bladder incontinence Pulse: Rate, rhythm(regular/irregular), character(normal or
If Dry cough: Heart burn, post nasal drip, wheeze, drug usage, not), volume ( high, normal, low), blood vessel thickening,
ear pain or discharge. peripheral pulsations [Carotid, brachial, radial, femoral,
If productive cough: Amount of sputum, colour, smell, loss of popliteal, posterior tibial, dorsalis pedis], radio femoral
consciousness, choke up, foreign bodies. delay or radio radial delay (present or not)
2. Breathlessness: onset, duration, progression, grade, postural BP: 120/80 mm Hg measured on Rt Upper arm In supine
variation (orthopnoea, PND), diurnal and seasonal variation, position
exertion, wheeze, snoring Respiratory Rate: Thoraco abdominal in females, Abdomino
Sweating, headache, syncope, palpitations, dysphagia, stridor, thoracic in males.
hoarseness of voice.
3. Chest Pain: ___ duration, site, onset, progression, episodes,
type, radiation, aggravating and relieving factors, relation to SYSTEMIC EXAMINATION-Respiratory
food intake, associated night sweats or fever.
1. Upper Respiratory Tract:
4. Fever: duration, grade, intermittent/continuous, swaeting,
Nose: Alae Nasi, septum, polyps
chills/rigors, associated with headache, vomiting.
Oral Cavity: Teeth, Gums, tonsils, pharynx.
5. Haemoptysis: duration, quantity, clots, cough, food particles,
Check sinus tenderness.
melena, epistaxis, haematochezia, haematuria, hum bleeding,
2. Examination of Chest Proper:
rashes.
INSPECTION:
H/O recurrent cold or sore throat.
1. Shape of Chest
H/O hoarseness of voice
2. Trachea position central or not
H/O loss of consciousness, perioral surgeries, repeated choking
3. Apical Impulse
episodes.
4. Movements of the chest: Respiratory rate, Type, rhythm,
H/O convulsions.
any accessory muscles involved, intercostal indrawing
H/O joint pains
5. Skin over the chest: Any engorged veins, sinuses,
H/O BCG vaccination
subcutaneous nodules, intercostal scars, intercostal
H/O blood transfusions, or recent vacciantions.
swellings.
6. All the areas are normal.
SUMMARY:
7. Trail sign: Prominence of sternal head of SCM to the side
A __ year old male/female patient presented with ___(positive
of deviation of trachea.
findings).
PALPITATION:
Anatomical:
1. Temperature and tenderness
Etiological:
2. All inspector findings confirmed. (Tracheal position, apex
Pathological:
beat)
PAST HISTORY: 3. Expansion of the chest.
H/O similar complaints in the past 4. Dimensions:
H/O HTN, DM, TB, Hypo/Hyperthyroidism/ Epilepsy/ Circumefernce: Rt / Lt
Asthma/COPD/ CAD/ Blood transfusions 1. Transverse
Any surgeries, drugs usage, allergies. 2. AP
3. Hemi thorax
FAMILY HISTORY: 5. Tactile vocal fremitus: Palpable crepts, thrill, rub
None of the patient’s parents, siblings or first degree relatives have or 6. Any bony tenderness.
have had similar complaints or any significant co morbidities. Ask for TB, PERCUSSION:
HTN, DM, Br Asthma. Direct: On the clavicle, sternum, manubrium, body.
PERSONAL HISTORY: Kronig’s isthmus
Diet, Appetite, Bowel, Bladder, Sleep, Addictions (Alcohol and Indirect percussion: Anterior (Mid clavicular line 2-6th ICS),
Smoking) Lateral (Mid axiallary line 4-7th ICS, posterior (Mid scapular
line 9th rib)
GENERAL EXAMINATION
Tidal percussion
A __ year old patient, supine decubitus who is ___ built __
 Traube space Traube's Space boundaries: (Normally resonant)
Topographical Liver, heart. Superiorly: 6th rib
Laterally: Mid axillary line
AUSCULATION: Medially: Left costal margin
1. Normal breath sounds: both sides, type of breathing. Dullness: Splenomegaly, Full stomach, Left Pleural
2. Any abnormal sounds Effusion, Carcinoma involving gastric fundus, Enlarged left
3. Any adventitious sounds lobe of liver, Achalasia cardia
Vocal resonance- All areas, both sides.
Tidal Percussion
OTHER SYSTEMS: Percuss down the back until the normal hyperresonance
CNS- No facial asymmetry, All reflexes are normal of the lungs becomes dull over the diaphragm. Then
Respiratory: Normal Vesicular Breath sounds, No adventitious simply have the patient breath in and out deeply while
sounds heard continuing to percuss. The sound should wax and wane.
GIT- No HSM(hepatosplenomegaly), No Ascites Loss of tidal percussion: Pleural effusion, Hyperinflation
such as emphysema from a maximally contracted
DIAGNOSIS: diaphragm
This is a case of left/right sided pleural effusion without any
complications. Pectus Excavatum (Funnel Chest): depression of sternum;
(Anatomical: Pleura, Pathological: Pleural effusion, etiological: in severe cases may compress heart and great vessels.
infection) Pectus Carinatum (Pigeon chest): anterior displacement of
sternum, usually benign.
Flail Chest: secondary to multiple rib fractures, depression
NOTES: of diaphragm causes injured area to cave inward
MMRC (Modified Medical research council) Dyspnea grading: producing a "paradoxical thoracic movement" in
breathing.
0 Dyspnea only with strenuous exercise
1 Dyspnea when hurrying or walking up a slight hill Accessory muscles:
2 Walks slower than people of the same age because of dyspnea Inspiration: scalene, trapezius, pectorals
or has to stop for breath when walking at own pace
Expiration: abdominal muscles and latissimus dorsi
3 Stops for breath after walking 100 yards (91 m) or after a few
minutes
4 Too dyspneic to leave house or breathless when dressing

For wheeze and stridor ask for musical sounds.

Orthopnea in lung conditions: COPD, Diaphragmatic palsy,
Neuromuscular disease.
Trepopnea: Orthopnea while lying on one side.
PND is specific for cardiac diseases ( cause is overload of right
heart)
Patient with lung parenchyma diseases, is more breathless while
lying on affected side.
PLEURAL Pain: Sharp, localized, stabbing type, sudden in onset,
no radiation.
Sudden onset chest pain: Rule out MI, Pneumothorax,
embolism, acute pneumonia.
Pleural Effusion= Mostly dry cough.
Mucoid/expectorant cough= Airway diseases
purulent cough= Infection.
Smoking Index: Number of cigarattes/day x Number of years
SI<100 = Mild
SI 100-300 is Moderate smoker
SI 300+ Heavy smoker.
Ex smoker is hasn’t smoked since 1 year
Non smoker, Less than 100 cigarettes in life.
Kronig’s Isthmus : It is a band of resonance representing lung
apex. It is a band of resonance representing lung apex.
Laterally: It is marked by a line joining 2 points:
1. The junction of the medial 2/3 of the clavicle with lateral 1/3.
2. The junction of the medial 1/3 of the scapular spine with the
lateral 2/3.
Medially: It is marked by a line between the sternal end of
clavicle and 7th cervical spine
Impaired dullness: Fibrosis, Upper Lobe Collapse and Mass
Hyper-resonant: Emphysema, Hydropneumothorax
SURGERY
 BREAST CASE PROFORMA After taking informed consent, patient is in sitting position
with arms by the side of her body.
Name: Age: Sex: Occupation: Address: INSPECTION:
HISTORY 1. Breast: i: Position ii: Size and Shape iii: Any puckering or
dimpling iv: Any swelling/ulcer visible
Chief Complaints: 2. Skin over breast: i: Colour & Texture ii: Engorged veins iii:
Lump in the Rt/Lt breast since Dimple, retraction, puckering iv: Peau d’orange v: Any visible
Pain in the lump/breast since nodules vi: Ulceration/fumigation
Ulceration over breast since 3. Nipple: i: Presence ii: Position iii: Number iv: Size and
Nipple discharge since Shape v: Surface vi: Discharge
Swelling in the axilla since 4. Areola: i: Colour ii: Size iii: Surface & Texture
History of Present Illness: 5. Arm & Thorax
Patient was apparently asymptomatic __ days back when he 6. Axilla and Supraclavicular Fossa
developed 7. Raise Arms above head
1. Lump- Onset (noticed how), duration, progression, any H/O PALPITATION: *Palpate normal breast first* [Palmar
trauma, any H/O rapid growth surface of fingers with hand flat] Normal breast gives firm
2. Pain- site, onset, duration, character, relation with swelling, lobulated impression with nodularity. Now affected side:
relation with menstrual cycle Confirm inspection findings, Feel axillary tail just behind
3. Ulcer-like ulcer nipple
4. Nipple discharge- duration, type, from one opening/multiple LUMP: i Local rise of Temperature - Skin tenderness (local
openings, amount, foul smelling or not tenderness) ii: Situation (quadrant) iii Number iv: Size &
5. Retraction of nipple Shape v: Surface vi: Margins vii: Consistency, viii: Fluctuation
6. Swelling in the axilla ix: Trans illumination x: Fixity to skin xi: Fixity to breast
Any H/O chest pain, cough, hemoptysis tissue xi: Fixity to underlying fascia and muscles xiii: Fixity to
Any H/O pain abdomen, jaundice chest wall xiv: Palpation of Nipple Areolar complex xv:
Any H/O low back ache, ache in limbs, Ulcer
Any H/O headache, LOC, vomiting, seizures xvi: Lymph Nodes
Any H/O loss of weight, loss of appetite A: Axillary Nodes: 1. Pectoral 2. Brachial 3. Subscapular 4.
PAST HISTORY: Central 5. Apical
H/O similar complaints B. Cervical Lymph Nodes: Supraclavicular
-Any H/O HTN, DM, CAD ,TB, Hypo/Hyperthyroidism/ Epilepsy/ OTHER SYSTEMS:
Asthma/COPD/ / Blood transfusions CVS- Normal S1 S2 heard, No murmurs.
Respiratory: Normal vesicular breath sounds, No
adventitious sounds, GIT- Per Abdomen Bones- Normal
Drug and Treatment History: H/O previous surgery for breast
CNS- No Facial asymmetry, all reflexes are normal
FAMILY HISTORY: PROVISIONAL DIAGNOSIS:
None of the patient’s parents, siblings or first degree relatives have or This is a case of single, fixed, hard lump in upper outer
have had similar complaints or any significant co morbidities quadrant of rt/lt breast suggestive of carcinoma of TNM
stage with no evidence of local or systemic complications
Obstetric and Menstrual History= Age of menarche, age of [This is a case of single mobile firm lump in lower outer
menopause, marital status, number of pregnancies, breast quadrant of Lt/Rt breast, probably benign, most probably a
feeding, LCB, use of HRT/contraceptives fibro adenoma of the Lt/Rt breast.]

PERSONAL HISTORY: [Important] NOTES:

Diet, Appetite, Bowel, Bladder, Sleep, Addictions (Alcohol and Discharge from Nipple
Smoking), Any Allergies Blood – Duct papilloma, carcinoma breast
Pus – Breast abscess
PHYSICAL EXAMINATION
Milk – Lactation, galactocele, mammary fistula
1. GENERAL SURVEY
Serous/Greenish – Fibroadenosis, duct ectasia
- General assessment of Illness- ECOG (Zubroad scale)/Karnofsky
score) Retraction of Nipple
-Mental state and intelligence (CCC) Circumferential – Carcinoma breast
-Build, state of nutrition Slit Like – Mammary duct Ectasia with periductal mastitis
-Decubitus and Attitude, Any facies
[A __ year old patient, supine decubitus who is __ built __ Mondor’s Disease: Thrombophlebitis of the superficial veins
nourished is conscious, coherent, cooperative, and comfortably of the breast and anterior chest wall
seated/lying on the bed, well oriented to time, place and person] Cancer en cuirasse: Multiple cancerous nodules and
There is No Pallor, Icterus, cyanosis, koilonychias, generalised thickened skin like a coat of Armor in arms and thorax.
lymphadenopathy and no pedal edema. Tethering (Dimpling): Infiltration of Astley Cooper’s
VITALS: Temperature: Pulse, RR, BP. ligament, pulls the skin inwards creating a dimple or
puckering over the breast. Tumour moves independent of
LOCAL EXAMINATION-Breast skin.
Fixity: Infiltration of skin itself by the tumor. Tumor cannot
be moved, i.e. skin cannot be pinched. TNM staging: T4b axillary lymph node metastases or metastases in Ipsilateral
Peau D’Orange: Lymphatics of skin being obstructed. supraclavicular lymph nodes with or without axillary or
Considered as skin involvement. internal mammary lymph node involvement
Level of Axillary Nodes: N3a Metastases in ipsilateral infraclavicular lymph nodes
Level 1-Lateral to lateral border of pectoralis minor N3b Metastases in ipsilateral internal mammary lymph
• Anterior (Pectoral) • Posterior (Subscapular) • Lateral node(s) and axillary lymph node(s)
(Brachial) N3c Metastases in ipsilateral supraclavicular lymph node(s)
Level 2-Behind pectoralis minor
• Central • Rotters (between major and minor) Chemotherapy: For all node positive cancers, >1cm in size,
Level 3-Medial to medial border of pectoralis minor triple negative cases, CMF REGIMEN= Cyclophosphamide,
• Apical (Infraclavicular) Methotrexate, 5-Fluorouracil 28 day cycle

Inspection of the breast with the arms raised over the

head—to look for any nipple deviation or any skin changes.
Inspection with the patient sitting and leaning forward—to
look for whether both the breast fall forward equally or
there is fixity of the diseased breast.
Inspection with the patient sitting and pressing her waist
with the hands—to look for any evident skin changes.

Bi RADS (Breast Imaging Reporting and Data System)

1. Negative
2. Benign finding
3. Probably benign finding
4. Suspicious abnormality
5. Highly suggestive of malignancy
6. Biopsy confirmed malignancy

TNM Staging of Breast Cancer:

Tx—primary tumor cannot be assessed*
T0—no evidence of primary
Tis—carcinoma in situ (Tis DCIS, Tis LCIS, Tis Paget’s)
T1— tumour less than 2 cm
T2—Tumour more than 2 cm but less than 5 cm
T3—Tumour more than 5 cm in greatest dimension
T4—Tumor of any size with direct extension to the nchest
wall and or to the skin (ulceration or skin nodule and peau d’
orange). Invasion of dermis alone does not qualify as T4
T4a—Extension to chest wall, not including pectoralis
muscle adherence/invasion
T4b—Ulceration and or ipsilateral satellite nodules and or
edema (including peau d’ orange) of the skin which do not
meet the criteria for inflammatory carcinoma Sentinel lymph node is the lymph node which is in a direct
T4c—Both T4a and T4b drainage pathway from the primary tumor. Sentinel lymph
T4d—Inflammatory carcinoma node is the first node encountered by the tumor cells and its
histological status predicts distant lymph basin status with
Nx Regional lymph nodes cannot be assessed (e.g. regard to metastasis
previously removed) QUART is quadrantectomy, axillary dissection (level I-III) and
N0 No regional node metastases postoperative radiotherapy.
N1 Ipsilateral level 1 and 2 axillary lymph nodes (mobile) Simple Mastectomy: Surgical removal of the whole of breast
N2 Ipsilateral level 1 and 2 axillary lymph nodes that are tissue superficial to the pectoral fascia is called Simple
clinically fixed or matted or in clinically detected ipsilateral Mastectomy. That means superficial fascia is left behind or
internal mammary nodes in the absence of clinically evident not removed. Total Mastectomy: Surgical removal of the
axillary lymph node metastases whole of breast tissue including the pectoral.
N2a Ipsilateral level 1 and 2 axillary lymph nodes fixed to Modified Radical Mastectomy: Removal of the whole of
one another (matted) or to other structures breast tissue including the pectoral fascia and all 3 levels
N2b Ipsilateral internal mammary nodes and in the absence axillary lymph nodes.
of clinically evident level 1 and 2 axillary lymph node Patey’s MRM = P major is preserved but minor removed.
metastases Scanlon’s MRM= P minor divided, Auchincloss MRM=
N3 Metastases in ipsilateral infraclavicular (level 3 axillary) Pminor retraced but not divided.(Done nowadays)
lymph nodes with or without level 1, 2 axillary lymph node Halsted Radical=Both muscles removed
involvement or in clinically detected ipsilateral internal
mammary lymph nodes with clinically evident level 1 and 2
 HERNIA CASE PROFORMA LOCAL EXAMINATION-Hernia

Name: Age: Sex: Occupation: Address: After taking informed consent patient is exposed from
[Young Age—indirect, Old Age—direct] umbilicus to midthigh level & examined in supine & standing
positions
HISTORY INSPECTION:
1. Swelling: Size & Shape (Pyriform—indirect Hemispherical —
Chief Complaints:
direct), Position and Extent, Visible peristalsis
Swelling in the Rt/Lt groin since
2. Skin over Swelling
Pain over the swelling since
3. Impulse on coughing
History of Present Illness:
4. Position of penis
Patient was apparently asymptomatic __ days back when he
NO scars/sinuses/ engorged veins/visible peristalsis.
developed swelling in the Rt/lt inguinal region since ____.
PALPITATION:
Swelling was spontaneous in onset on straining. First appeared in
1. Temperature and Tenderness 2. Swelling: Site, Size, Shape,
the groin and gradually increased in size and now limited to
Extent, Surface, Skin over swelling, Consistency [Consistency:
groin/extends to the scrotum.
Soft elastic—intestine Doughy granular—omentum],
Any change in swelling on standing, walking, straining, lying down.
Reducibility, Get above the swelling [Get above the swelling is a
Swelling is reducible/non reducible on lying down / partially
classical feature of hydrocele].
reducible/needs any manoeuvre to reduce it.
3. Cough impulse ( If +ve means it has communication with
Any H/O gurgling sound in swelling/scrotum (enterocele)
peritoneal cavity)
If reducible swelling, any pain, abdominal distension/vomiting.
4. Ring Invagination test: Only test in hernia; done in lying
Pain- site (groin, scrotum all over the abdomen), onset, duration,
position. Swelling should be reducible & Lax of skin should be
character (dull aching or severe pricking, Aggravating and relieving
there for invaginating (so this test could not be done in
factors (walking, exercise, lying down), progression of pain,
females)
radiation.
Reduce the swelling. -> For right side, invaginate with right
H/O chronic cough, TB/ Asthma/Resp disease
little finger into the superficial ring. -> Rotate the little finger
H/O constipation, altered bowel habits, tenesmus, bloody stools
medially so that the pulp faces medially. ->Note the direction of
(Anorectal strictures/ Anal carcinoma)
entry and site of impulse.
H/O dysuria/urgency/hesitancy/altered stream/burning micturition/
Look for:
haematuria [BPH, Prostate Ca, Urethral stricture]
Strength of superficial ring: Normal ring admits only the tip
Direction of canal: Direct hernia—directly backwards Indirect—
PAST HISTORY: goes upwards, backwards and laterally
H/O similar complaints same side/other side Site of impulse: Pulp—direct Tip—indirect
H/O hernia surgery-side/surgery/mesh kept or not 5. Deep Ring occlusion test: After reducing the contents,
-Any H/O HTN, DM, CAD ,TB, Hypo/Hyperthyroidism/ Epilepsy/ patient in standing position, occlude the deep ring with thumb.
Asthma/COPD/ / Blood transfusions Ask the patient to cough. If swelling appears – Direct
Any H/O appendectomy Does not appear – Indirect [Most important test]
6. Zieman's technique [3 Finger]:
Drug and Treatment History: H/O aspirin intake, any surgeries For right side inguinal hernia, place the right hand – Index
finger over deep ring – Middle finger over superficial ring – Ring
FAMILY HISTORY:
finger over saphenous opening
None of the patient’s parents, siblings or first degree relatives have or have
had similar complaints or any significant co morbidities See where the impulse is felt
Alpha 1 antitrypsin deficiency, Connective tissue disorders – Direct hernia—superficial ring – Indirect hernia—deep ring
– Femoral hernia—saphenous opening
PERSONAL HISTORY: PV and PR should be done. PR for BPH.
Diet, Appetite, Bowel, Bladder, Sleep, Addictions (Alcohol and PERCUSSION: Enterocele or Omentocele (resonant vs dull)
Smoking), Any Allergies (Nicotine interferes with collagen AUSCULTATION: Bowel sounds
maturation) Others
PHYSICAL EXAMINATION 1. Testis: ‘Traction Test’ to find whether the inguinal swelling is
1. GENERAL SURVEY an Encysted Hydrocele of Cord.
- General assessment of Illness- ECOG (Zubrod scale)/Karnofsky 2. Epididymis.
score) 3. Penis: (Phimosis, Penile strictures, Pinhole meatus)
-Mental state and intelligence (CCC) 4. Regional nodes. 5. Opposite groin
-Build, state of nutrition OTHER SYSTEMS:
-Decubitus and Attitude, Any facies CVS- Normal S1 S2 heard, No murmurs.
[A __ year old patient, supine decubitus who is __ built __ nourished Respiratory: Normal vesicular breath sounds, No adventitious
is conscious, coherent, cooperative, and comfortably seated/lying sounds, GIT- Per Abdomen soft
on the bed, well oriented to time, place and person] CNS- No Facial asymmetry, all reflexes are normal
There is No Pallor, Icterus, cyanosis, koilonychias, generalised PROVISIONAL DIAGNOSIS:
lymphadenopathy and no pedal edema. This is a case of right/left sided, complete/incomplete,
VITALS: Temperature: Pulse, RR, BP. reducible/irreducible, indirect/direct inguinal hernia containing
intestines/omentum without any complications at present.
NOTES:
Complications
1. Irreducibility: Contents of Inguinal Canal:
i. Crowding of the contents ii. Adhesion between sac and contents Ilioinguinal nerve Spermatic cord in male, round ligament in
iii. Adhesion between contents iv. Adhesion between sac. female
2. Obstruction: Four cardinal features Contents of spermatic cord:
i. Colicky abdominal pain ii. Vomiting iii. Abdominal distension iv. Arteries : Testicular Arter, Artery of Vas, Artery to Cremaster
Obstipation (Absolute constipation)—not passing flatus and feces. Veins : Pampiniform plexus of veins, Veins corresponding to
3. Strangulation: (Obstruction + irreducibility + Arrest of blood Arteries
supply) Lymphatics of testis, Testicular plexus of sympathetic nerves
i. Colicky abdominal pain if continues and becomes gangrenous pain Genital branch of genitofemoral Nerve and Vas deferens
disappears ii. Sudden increase in size of hernia; becomes tense and Hesselbach Triangle
tender. Weak spot in anterior abdominal wall through which direct
Malgaigne’s bulging hernia appears.
Oval, longitudinal, bilateral bulging produced on straining, in Medial: Outer border of rectus abdominis
inguinal region or above it; and are parallel to medial half of inguinal Lateral: Inferior epigastric vessels
ligament • Present in direct hernia • Indicates poor muscle tone • Below: Medial part of inguinal ligament
Signifies hernioplasty is the treatment Floor: Fascia transversalis – Traversed by medial umbilical
fold; (Obliterated Umbilical Artery)
TAXIS:
Method of reducing the inguinal hernia Procedure: Flex the knee, Signs of Strangulated Hernia
Adduct and internally rotate the hip -> Relaxes the abdominal On examination the hernia is tense, On examination the
muscles *with the thumb and fingers hold the sac; guide with other hernia is tense. Extremely tender and irreducible. There is
hand at superficial ring* no expansile cough impulse. The spasms of pain continue
European Hernia Society System: until peristaltic contractions cease with the onset of
Primary or recurrent = (P/R) ischaemia. Paralytic ileus , peritonitis , and septicaemia
Lateral (indirect), Medial (Direct) or Femoral (L/M/F) develop. Spontaneous cessation of pain may be a sign of
Defect size in finger breadths (multiples of 1.5cm) perforation
[PL2= Primary indirect inguinal hernia 3cm defect size]
Surgeries:
Demonstrate hernia in children: [Gornall's Test] Herniotomy= Children (due to good muscle tone)
– Child held from back by both hands of clinician on its abdomen Neck of sac transfixed, ligated and excised.
– Abdomen is pressed and child is lifted up Herniorraphy (Bassini)= Middle age. Herniotomy + Post wall repair
– Hernia appears due to increase in the abdominal pressure exerted by suturing conjoint tendon with inguinal ligament.
Hernioplasty: Herniorraphy + mesh. Lichtenstein tension free mesh
Reducibility (prolene) repair. For recurrent, old age, family history.
a. Intestine: Last part is easy to reduce; Initial part is difficult to Congenital Hernia is due to patent processes vaginalis and it is
reduce; gets reduced with gurgling sound. removed in surgery hence only herniotomy.
b. Omentum: First part easy to reduce, last part is difficult because Laparoscopic surgeries:
omentum adheres to fundus of sac. TAPP- Transabdominal preperitoneal repair
Boundaries of Inguinal Canal TEP- Total extraperitoneal repair
Anterior Wall: External oblique aponeurosis, arched fibers of Points:
internal oblique laterally. Maydl's hernia (Retrograde strangulation) ‘W’ shaped hernia
Posterior Wall: Fascia transversalis, conjoint muscles (tendon) in Sliding Hernia: Part of the posterior wall formed not only by the
medial half. peritoneum but also by part of retroperitoneal structures. [Urinary
Floor: Grooved part of external oblique aponeurosis; Medial end bladder, cecum, sigmoid colon]
there is lacunar ligament. Littre's Hernia : Meckel's diverticulum is seen in the sac
Roof: Conjoint muscles (Internal oblique and transversus abdominis) Pantaloon hernia: (Saddle) Dual hernia (direct and indirect)
Richter’s hernia: Hernia in which the sac contains only a portion of
Midpoint of the inguinal ligament: The inguinal ligament runs from the wall of the intestine (usually small intestine).
the pubic tubercle to the anterior superior iliac spine, so the Amyand’s Hernia: Appendix in the sac.
midpoint is halfway between these structures. The opening to the
inguinal canal (deep inguinal ring) is located just above this point.
Mid-inguinal point: Halfway between the pubic symphysis and the
anterior superior iliac spine. The femoral artery crosses into the
lower limb at this anatomical landmark.
Deep Inguinal Ring Lies between the midpoint of inguinal ligament
& the midinguinal point (1cm above the inguinal ligament)
Superficial Ring Lies supero-lateral to the pubic tubercle. Point of
emergence of spermatic cord (male) or round ligament and
coverings (female)
 CHRONIC/MASS ABDOMEN CASE PROFORMA [A __ year old patient, supine decubitus who is __ built __
nourished is conscious, coherent, cooperative, and
Name: Age: Sex: Occupation: Address: comfortably seated/lying on the bed, well oriented to time,
HISTORY place and person]
There is No Pallor, Icterus, cyanosis, koilonychias,
Chief Complaints: generalised lymphadenopathy and no pedal edema.
Pain Abdomen since VITALS: Temperature: Pulse, RR, BP.
Vomiting since
LOCAL EXAMINATION-Abdomen
Sensation of fullness after meals since
Hematemesis since After taking informed consent, patient is in supine position
Passage of black stools since with arms by the side of her body.
Yellowish discolouration of eyes since INSPECTION:
Loss of appetite since 1. Skin and Subcutaneous tissue: Any visible swelling,
Alteration of bowel habit since engorged veins, any nodules
Fever since 2. Umbilicus: Tanyol’s sign, appearance (flat, everted,
Lump in the abdomen since inverted]
History of Present Illness: 3.Contour of abdomen
Patient was apparently asymptomatic __ days back when he 4.Movement (of abdomen) with respiration, any visible
developed peristalsis, any pulsatile movements
1. Pain- site, onset, duration, character, relation with food, 5.Swelling/lump: condition of skin over lump, position, size,
micturition, defecation, Aggravating and relieving factors. shape, movements with respiration,
2. Lump- Onset (noticed how), duration, progression, size when 6. Hernia orifices, scrotum, renal angle, left supraclavicular
first noticed, site, fever, any other lumps fossa
3. Vomiting: character, amount, frequency, relation with food, PALPITATION:
relief of pain, projectile/effortless, colour, taste, smell, and any Superficial Palpation: Temperature, tenderness, feel of
blood in vomit. abdomen, any palpable lump (extra abdominal like lipoma,
4. Dyspepsia: fullness after food, heart burn, belching myoma, fibroma, hematoma)
5. Hematemesis: Duration, number of bouts of vomit, colour, Deep Palpation: Check for tender spots- Gastric point,
amount, associated with melena or not duodenal point, gall bladder point, amoebic point, Mc
6. Jaundice: onset, duration, any prodromal symptoms, H/O Burney point, renal point. Also check Murphy Sign
biliary colic, progression of jaundice, associated symptoms Fluid Drill
(itching, stool, urine colours) Organs: Liver, Spleen, Kidney, gall bladder, stomach,
H/O fever, rigor, pain in Right upper Quadrant (cholangitis) pancreas, colon.
7. Bowel Habit: Any change, any bleeding PR or black tarry stools, Any other lump: Local temp, tenderness, position, size,
mucus in stools, tenesmus, colour, quantity of stool, smell surface, margin, consistency, movement with respiration,
Any Loss of appetite, Any loss of weight mobility, ballotable.
H/O fever See if its parietal or intraabdominal [Carnett’s test (leg lifting
Urinary symptoms: loin pain, frequency, difficulty, altered stream, test)
burning micturition, hematuria, pyuria Pulsatile or not
PAST HISTORY: Hernia sites (expansile impulse should be tested)
H/O similar complaints Palpate spleen, liver, kidney, supraclavicular fossa
-Any H/O HTN, DM, CAD ,TB, Hypo/Hyperthyroidism/ Epilepsy/ PERCUSSION: Liver span, Shifting Dullness, Percussion over
Asthma/COPD/ / Blood transfusions lump, renal angle, supraclavicular fossa., Hydatid thirll
Any H/O Jaundice, Tonsillitis, Typhoid, Syphilis AUSCULTATION: Kenawy Sign
MEASUREMENTS: Xiphisternum to umbilicus, Umblicus to
Drug and Treatment History: H/O aspirin intake, any surgeries SP, Spino umblical, abdominal girth.
PV and PR should be done.
FAMILY HISTORY: OTHER SYSTEMS:
None of the patient’s parents, siblings or first degree relatives have or CVS- Normal S1 S2 heard, No murmurs.
have had similar complaints or any significant co morbidities
Respiratory: Normal vesicular breath sounds, No
PUD, Crohns, Ulcerative Colitis
adventitious sounds, GIT- Per Abdomen Bones- Normal
PERSONAL HISTORY: [Important] CNS- No Facial asymmetry, all reflexes are normal
Diet, Appetite, Bowel, Bladder, Sleep, Addictions (Alcohol and PROVISIONAL DIAGNOSIS:
Smoking), Any Allergies This is a case of single, fixed, hard lump in upper outer
quadrant of rt/lt breast suggestive of carcinoma of TNM
PHYSICAL EXAMINATION stage with no evidence of local or systemic complications
1. GENERAL SURVEY [This is a case of single mobile firm lump in lower outer
- General assessment of Illness- ECOG (Zubroad scale)/Karnofsky quadrant of Lt/Rt breast, probably benign, most probably a
score) fibro adenoma of the Lt/Rt breast.]
-Mental state and intelligence (CCC)
-Build, state of nutrition NOTES:
-Decubitus and Attitude, Any facies
 Right Hypochondrium Epigastric Left Hypochondrium
Cholecystis, Hepatomegaly, Splenomegaly, Gastric Murphy's sign can be elicited by placing your examining
Cholangiocarcinoma, Pancreatic Ca, Pancreatic fingers over the gallbladder area and then asking the patient
Hepatmegaly, Liver Ca abscess, pseudocyst, Abscess, to take a deep breath. If Murphy's sign is positive, there will
pseudocyst, Kidney-PCKD, TB, be sudden accentuation of the pain on inspiration and
Gastric Ca Hydronephrosis, Colon inspiration will be inhibited.
ca
Right Lumbar Periumblical Left lumbar
Hydronephrosis, RCC AAA, Tumour, Hydronephrosis, RCC
Hernia, Crohn’s
Right Iliac Suprapubic Left Iliac
Colon Ca, Crohn’s, Distended Diverticular abscess,
Appendix, Amoebic bladder, Hernia, Colorectal Ca
abscess Neuroblastoma

Courvoisier’s law

This states that in the presence of jaundice, a palpable gallbladder

makes gallstone obstruction of the common bile duct an unlikely
cause (because it is likely that the patient will have had gallbladder
stones for some time and these will have rendered the wall of the
gallbladder relatively fibrotic and therefore non-distensible).
However, the converse is not true, because the gallbladder is not
palpable in many patients who do turn out to have malignant bile
duct obstruction.

Liver Palpation:
Starting in the right iliac fossa, deeply palpate in this region and ask
the patient to take a deep breath (this contracts the diaphragm,
pushing the liver down) Repeat this a little superiorly until the liver
edge is felt (NB normally, the liver edge is not palpable below the rib
cage. On deep inspiration, the liver edge may be felt in a normal
individual) Examine/comment on size (cm or fingerbreadths) from
costal margin; any tenderness Percuss the lower and upper liver
borders By percussing from the thorax inferiorly and from the iliac
fossa superiorly, the liver may be identified as dull (cf the resonant
chest and less dull normal bowel)

Spleen Palpation:

Percussion can be done in an identical fashion except on the left.

However, others prefer to percuss inferolaterally across Traube’s
space. This is a crescent shaped area bordered superiorly by the left
6th rib; anteriorly by the left anterior axillary line and inferiorly by
the left costal margin. Normally, the stomach lies deep to Traube’s
space and it is resonant to percuss. In splenomegaly, it can be dull.
If resonant percussion is present at the left 6th rib, anterior axillary
line, ask the patient to breathe in deeply and reassess.
Palpation is also done in a similar fashion except palpation usually
begins at the right iliac fossa and makes its way diagonally across
the abdomen. Some also might reach over with their left hand to
push forward the lower left rib cage and soft tissues with the right
hand palpating below the costal margin on inspiration.

Kidneys Palpation:
To ballotte the kidneys, reach around with your opposite hand to
place under the patient (just under the 12th rib) and lifting the
tissues anteriorly. With your free hand, deeply palpate the upper
quadrant, trying to feel the kidney between both hands. This is also
usually best done with deep inspiration.
To percuss the kidneys, ‘thump’ the costovertebral angles with the
ulnar surface of a fist (enough to be forceful without trying to cause
pain). This may reveal kidney tenderness. NB It is only really used
when kidneys appear tender on ballotting.
 PAROTID SWELLING CASE PROFORMA
2. Skin over Parotid: Any redness, edema, ulceration, sinus,
Name: Age: Sex: Occupation: Address: fistula, discharge, fungation.
HISTORY 3. Stenson Duct: Retract cheek with spatula and inspect the
duct (opposite to 2nd upper molar) Look for any pus, serous
Chief Complaints:
discharge, blood.
Swelling below and in front of Rt/Lt ear since __
4. Fistula: Note position and relation to gland/duct
History of Present Illness:
5. Inspection for other swellings in the neck
Patient was apparently asymptomatic __ days back when he developed
1. Swelling- Onset, duration, size, site, progression (recent increase of PALPITATION:
size), associated with pain/or not/ while eating, any aggravation with Confirm inspection findings
food intake (excessive salivation, size or pain increase), any H/O 1&2. Local rise of Temperature -& Local tenderness
discharge in the mouth (purulent etc) or also fever, any H/O 3. SWELLING: Number, Site size, surface, margins, consistency,
pressure/infiltration on facial nerve ( drooling of saliva, difficulty in fluctuation, matted or not and fixity
closing eyes, deviation of mouth), any H/O significant loss of Curtain sign: Mobility
weight/anorexia/restriction of jay movements, any associated dryness of Clench Masseter muscle- See if swelling is mobile over it or not.
mouth, eyes Bimanual Examination: One finger of one hand inside mouth in
Pain: character (throbbing=abscess, colicky pain during meals= stone) front of tonsil, other hand outside, behind the ramus of
Discharge- for parotid fistula mandible.
Any other swellings in neck 4. Skin over swelling: Induration/Fluctuation/ Pitting on
Other sites of metastasis: pressure (Seen in Parotid abscess)
H/O Cough, haemoptysis, chest pain 5. Duct: Feel for duct by rolling finger over taut masseter,
H/O abdominal pain, jaundice, abdominal distention terminal part bidigitally with index finger inside mouth and
H/O pain in end of long bones, back ache thumb over cheek.
H/O headache, vomitings, convulsions 6. Fistula: Note its position in relation to gland or duct
PAST HISTORY: [masseteric or premasseteric]
H/O similar complaints 7. Examination of FACIAL NERVE
-Any H/O HTN, DM, CAD , Hypo/Hyperthyroidism/ Epilepsy/ 8. Lymph Nodes of the neck. Mostly pre auricular, parotid and
Asthma/COPD/ / Blood transfusions submandibular nodes are involved
H/O irradiation to neck, syphilis, cancer, TB 9.Movements of Jaw: Restricted in malignant.
Drug and Treatment History + Allergic History: + Immunization History [ Sialography: A watery solution of Lipidiol (Neohydriol) is
For Mumps vaccine injected into the orifice of the duct and skiagram is taken. ]
FAMILY HISTORY:
OTHER SYSTEMS:
None of the patient’s parents, siblings or first degree relatives have or have had
similar complaints or any significant co morbidities CVS- Normal S1 S2 heard, No murmurs.
H/O Lymphomas, TB history contact. Respiratory: Normal vesicular breath sounds, No adventitious
PERSONAL HISTORY: sounds, GIT- Per Abdomen
Diet, Appetite, Bowel, Bladder, Sleep, Addictions [Alcohol (for parotitis) CNS- No Facial asymmetry, all reflexes are normal
and Smoking], PROVISIONAL DIAGNOSIS:
This is a case of Rt/Lt sided swelling of superficial lobe of parotid
PHYSICAL EXAMINATION gland most probably neoplastic in origin, mostly a benign tumour
1. GENERAL SURVEY like pleomorphic adenoma with no complications at present.
- General assessment of Illness- ECOG (Zubroad scale)/Karnofsky score) NOTES:
-Mental state and intelligence (CCC) Levels of Neck Lymph Nodes:
-Build, state of nutrition [weight loss and cachexia] Level I - Submaxillary and submental
-Decubitus and Attitude, Any facies Level II - Upper jugular
A __ year old patient, supine decubitus who is __ built __ nourished is Level III - Middle jugular
conscious, coherent, cooperative, and comfortably seated/lying on the Level IV - Lower jugular
bed, well oriented to time, place and person. Level V - Posterior triangle
There is No Pallor, Icterus, cyanosis, koilonychias, generalised Level VI - Central neck nodes
lymphadenopathy and no pedal edema. Level VII - Anterior mediastinal
VITALS: Temperature: Pulse, RR, BP.

LOCAL EXAMINATION-Parotid Gland

After taking informed consent, patient is examined by exposure of the

face in sitting position with arms by the side of the body.
INSPECTION:
1. Swelling:
A. Superficial Lobe: Number, Position, raised ear lobule or not,
depression below ear lobule obliterated or not, size, shape, surface,
margins and extent
B. Deep Lobe: Inspect oral cavity (bulge in tonsil, lateral wall of pharynx)
VIRCHOW’S NODE: The left supraclavicular lymph node lying between Facial Nerve Branches:
the two heads of sternocleidomastoid is called the Virchow’s lymph The facial nerve emerges from the stylomastoid foramen and
node. This lymph node may be involved by metastasis from carcinoma enters the posteromedial surface of the parotid gland. It
stomach, testicular tumour, carcinoma oesophagus and bronchogenic initially divides into an upper division (zygomaticofacial) and
carcinoma a lower division (cervicofacial). Within the gland the nerve
branches and rejoins to form a plexus within the parotid
Palpation of Parotid Duct: gland (known as pes anserinus).
The parotid duct is palpated as it lies on the masseter muscle by a finger The nerve branches then emerges from the upper pole,
rolling across the masseter muscle as the patient clinches his teeth to anterior border and the lower pole of the parotid gland.
make the muscle taut. The terminal part of the duct is palpated These branches are
bidigitally between the index finger inside the mouth and the thumb Temporal
over the cheek. Zygomatic
To palpate deep part of parotid duct: By bidigital palpation with one Upper buccal
finger inside the mouth against the tonsillar fossa and the other finger Lower buccal
outside in the parotid region Mandibular
Parotid gland is divided into superficial and deep parts by the Cervical
faciovenous plane (parotid plexus)
Surgery: Superficial Parotidectomy
Differential Diagnosis: Removal of superficial part of the parotid gland along with
Adenolymphoma of the parotid gland, Chronic sialadenitis, Carcinoma of the tumour is called superficial parotidectomy.
parotid gland, Cervical lymphadenopathy due to tuberculous lesion or The incision starts below the zygomatic process just in front
metastasis of lymphoma, Lipoma, Fibroma Rhabdomyosarcoma. of the tragus then curves round the ear lobule and the
descend downwards along the anterior border of the upper
Frey’s syndrome: third of the sternocleidomastoid muscle.
This is a condition of gustatory sweating and flushing in the parotid
region following parotidectomy and may occur in more than 50% of
patients.
This follows injury to auriculotemporal nerve during surgery of parotid
gland or temporomandibular joint, or may follow accidental injury to the
parotid gland or temporomandibular joint. Following injury to
auriculotemporal nerve, the postganglionic parasympathetic fibre from
the otic ganglion reroutes to the sympathetic nerve from the superior
cervical ganglion destined to supply the cutaneous vessels and sweat
gland of the skin in the parotid region.
The parotid region is bounded by:
Anteriorly—by the posterior border of mandible
Posteriorly—by the mastoid process and the attached
sternocleidomastoid muscle
Below—by the posterior belly of digastric
Above—by the zygomatic arch.

The international classification of salivary tumours are:

1. Epithelial tumours
• Adenomas:
−− Pleomorphic adenomas
−− Adenolymphoma—Warthin tumour
−− Oxyphilic adenoma
−− Monomorphic adenomas
• Carcinomas:
−− Acinic cell carcinoma
−− Mucoepidermoid carcinomas
−− Adenoid cystic carcinoma
−− Adenocarcinoma
−− Squamous cell carcinoma
−− Undifferentiated carcinoma
−− Carcinoma superimposed on a pleomorphic adenoma
2. Non-epithelial tumours
• Haemangioma:
• Lymphangioma
• Neurofibroma
• Neurilemmoma
3. Malignant lymphoma
4. Unclassified and allied condition
 PVD [Peripheral Vascular Disease] CASE PROFORMA
There is No Pallor, Icterus, cyanosis, koilonychias,
Name: Age: Sex: Occupation: Address: generalised lymphadenopathy and no pedal edema.
HISTORY VITALS: Temperature, Pulse, RR, BP. Only take radial pulse
here.
Chief Complaints:
LOCAL EXAMINATION-PVD
Pain in Rt/Lf/both limbs since
Intermittent claudication since After taking informed consent, patient is examined by
Blackish discolouration since exposure of both limbs up till mid thigh
Ulcer since INSPECTION:
-Change in Colour
History of Present Illness: -Signs of Ischemia ( Thin skin, less hair growth, skin shine,
Patient was apparently asymptomatic __ days back when he loss of subcutaneous fat, trophic changes in nails-
developed brittle/ridges, minor ulcers in pressure areas
1. Pain- site, onset, radiation, aggrevated by -Buerger’s postural test (buerger’s angle)
walking/exercise/warmth, relived by rest [Buerger's test is used in an assessment of arterial sufficiency. The vascular
Intermittent claudication- site, duration, Boyd’s classification, angle, which is also called Buerger's angle, is the angle to which the leg has to
be raised before it becomes pale, whilst in supine decubitus. In a limb with a
claudication distance, agg/reliev factors normal circulation the toes and sole of the foot, stay pink, even when the
Rest pain- location, severtity, worse on lying down , relieved by limb is raised by 90 degrees. In an ischaemic leg, elevation to 15 degrees or 30
hanging down. degrees for 30 to 60 seconds may cause pallor. (This part of the test checks
for elevation pallor.) A vascular angle of less than 20 degrees indicates severe
Any changes to pain in response to cold
ischaemia.
2. Ulceration: Site, onset (traumatic, spontaneous), pain in ulcer, From a sitting position, in normal circulation, the foot will quickly return to a
discharge, progression. pink colour. Where there is peripheral artery disease the leg will revert to the
3. Blackish discolouration: Onset, site, progression, pain, H/O pink colour more slowly than normal and also pass through the normal
pinkness to a red-range colouring (rubor - redness) often known as sunset
difficutly walking/altered gait, H/O fever, trauma [To exclude foot. This is due to the dilatation of the arterioles in an attempt to rid the
traumatic gangrene] metabolic waste that has built up in a reactive hyperaemia. Finally the foot
H/O Impotence will return to its normal colour. This part of the test is known as a check for
rubor of dependency]
H/O paraesthesia (tingling, numbness)
-Capillary filling time=elevate legs-sit
and hang legs dow
H/O syncope, blackouts, loss of consciousness, blurred vision
-Venous refilling=elevate limbs for a while-lay legs flat
H/O chest pain, cough, cardiac symptoms
- Established Gangrene- Extent, color, type, line of
H/O abd pain, blppdy diarrhoes, abd angina
demarcation, limb area just above gangrene (Look for skip
H/O redness/pain along a line in superficial skin
lesions)

PALPITATION:
PAST HISTORY: Confirm inspection findings
H/O similar complaints in the other limb 1. Skin Temperature
-Any H/O HTN, DM, CAD ,TB, Hypo/Hyperthyroidism/ Epilepsy/ 2. Skin tenderness (local tenderness)
Asthma/COPD/ / Blood transfusions 3. Capillary refilling
Drug and Treatment History: Any H/O amputation, H/O 4. Venous refilling (Harvey’s sign=increased time)
Vasodilators usage 5. Crossed Leg test (Fuchsig’s test)
6. Cold and warm water test (To check for Raynaud)
FAMILY HISTORY: 7. Elevated Arm’s test (Roos Test=diagnostic of Thorcic
None of the patient’s parents, siblings or first degree relatives have or Outlet Syndrome)
have had similar complaints or any significant co morbidities 8. Allen’s test=patency of radial and ulnar arteries. Clench
fist tightly-press radial and ulnar artreies-open fist-palm is
Obstetric and Menstrual History= H/O recurrent abortions white-release radial pressure – assumes normal colour.
Same for ulnar artery.
PERSONAL HISTORY: 9. Branham/Nicoladonis Sign=for AV fistula. Pressure on the
Diet, Appetite, Bowel, Bladder, Sleep, Addictions (Alcohol and artery proximal to fistula will reduce the size of swelling,
Smoking), bruit disappears, pulse rate falls and pulse pressure is
Any Allergies normal.
10. Hyperabduction Manoeuvre (Wright)
PHYSICAL EXAMINATION 11. Gangrenous area= Dry (hard and shrivelled) vs Wet
1. GENERAL SURVEY (oedematous)
- General assessment of Illness- ECOG (Zubroad scale)/Karnofsky 12. Crepitus=seen in gas gangrene
score) 14. Limb above gangrene- Tenderness, oedema,
-Mental state and intelligence (CCC) 15. Palpation of blood vessels (++ = normal, + = plaplable
-Build, state of nutrition but feeble and - = not palpable.
-Decubitus and Attitude, Any facies Palpate both right and left of the following arteries:
Superficial Temporal
Facial artery
A __ year old patient, supine decubitus who is __ built __
Carotid
nourished is conscious, coherent, cooperative, and comfortably
Subclavian
seated/lying on the bed, well oriented to time, place and Axillary
person. Brachial
Ulnar
Radial Venous refilling time
Femoral After keeping the limb elevated for a while if it is laid flat on
Popliteal the bed, there will be normal refilling of veins within 5
Posterior Tibial seconds; but in ischemic limbs it will be delayed.
Anterior Tibial
Dorsalis Pedis Guttering of veins On raising the limb:
16. Neurological examination: Sensations, motor (power) •• Normal limb—gutter of veins at 90°
and reflexes- knee and plantar •• Ischemic limb—gutter at horizontal or raising to even 10°
17. Adson’s test= The patient will be sitting in a chair and
the radial pulse of the patient is felt. Patient is asked to turn Shionoya creteria for Buerger’s disease
the face to the same side where the pulse is being felt. Now History of smoking
ask the patient to take a deep breath to narrow the Onset before age of 50 years
cervicoaxillary channel. If the radial pulse disappears or Infrapopliteal arterial occlusions
becomes feeble it is suggestive of a cervical rib or a scalenus Either arm involvement or phlebitis migrans
anticus syndrome. Absence of risk factors for atherosclerosis other than smoking
18. Examination of regional lymph nodes PALPATION OF PULSES
Common carotid artery: Medial border of SCM at level of upper
AUSCULTATION: Along major arteries (Any bruit, systolic
border of thyroid cartilage against c6 carotid tubercle
murmur, machinery murmur
(Chassaignac’s tubercle)
MEASUREMENTS:
Superficial temporal artery: In front of tragus of ear over zygomatic
bone
OTHER SYSTEMS:
Subclavian artery: Midclavicular point. Patient lifting the shoulder
CVS- Normal S1 S2 heard, No murmurs.
to relax deep cervical fascia
Respiratory: Normal vesicular breath sounds, No
Axillary artery: Lateral wall of axilla in between the two axillary
adventitious sounds
folds
CNS- No Facial asymmetry, all reflexes are normal
Brachial artery: Front of elbow medial to tendon of biceps brachii
Radial artery: Lateral border of lower end of radius
PROVISIONAL DIAGNOSIS:
Femoral artery: Below the inguinal ligament midway between
anterosuperior iliac spine and pubic symphysis
This is a case of peripheral vascular disease affecting the __
Popliteal artery (3 methods)
lower limb with pregangrenous changes of great toe/
–– Supine: Flexing knee 40°, heel over bed; with thumbs over tibial
ischemic gangrene of great toe, most probably secondary of
tuberosity; other fingers are moved sideways to palpate popliteal
atherosclerosis/buerger’s disease.
artery over the posterior aspect of tibial condyles.
NOTES: –– Prone (knee flexed): Popliteal pulse felt over the posterior
Intermittent claudication is due to the muscle pain as a surface of lower end of femur.
result of accumulation of ‘P’ substance owing to inadequate –– Fuschig’s test: Crossed legs on sitting, inspect the oscillatory
flow” movements sitting on chair.
Posterior tibial artery: Over the medial aspect of ankle at a point
Boyd’s classification 1/3rd of way between tip of medial malleolus and point of heel and
Grade I - Patient experiences pain after walking some slightly inverting the foot to relax flexor retinaculum
distance and pain disappears and patient continues to walk Dorsalis pedis artery: Lateral to EHL tendon at the proximal first
(P-substances washed away) intermetatarsal space.
Grade II - Pain persists and still the patient continues to walk Anterior tibial artery: In front of the ankle midway between two
with limp malleoli and lateral to EHL tendon (EHL—extensor hallucis longus).
Grade III - Pain compels the patient to take rest Disappearing Pulse: After exercising the patient to claudication the
pulse previously palpable disappears is a sign of unmasking the
INSPECTION TESTS: preliminary stage arterial occlusion.
Buerger’s postural test
Patient lies supine, raise the legs one after other with knees Signs of Gangrene:
extended Change of colour(pale-bluish purple-black), Loss of temperature,
Normal limb: Remain pink even when raised to 90° Loss of sensation, Loss of pulsation, Loss of function
Look for: 1. Onset of pallor 2. Guttering of veins
•• Angle at which it appears is Buerger’s angle
•• Less than 30° implies severe ischemia

Capillary refilling time done after Buerger’s test

•• Make the patient sit and hang legs down
Normal limb: Will be pink as it was in elevated position
Ischemic limb: Pallor limb on elevation turns pink in
dependent position
Time taken is noted [20 to 30 seconds implies severe
ischemia]
 NECK LYMPH NODES CASE PROFORMA OTHER SYSTEMS:
CVS- Normal S1 S2 heard, No murmurs.
Name: Age: Sex: Occupation: Address: Respiratory: Normal vesicular breath sounds, No adventitious
HISTORY sounds, GIT- Per Abdomen
CNS- No Facial asymmetry, all reflexes are normal
Chief Complaints:
PROVISIONAL DIAGNOSIS:
Swelling in the Rt/Lt side of neck since __
Anatomical: Lymph nodes swelling of the neck (with the level)
History of Present Illness:
Pathological: Benign (Infective or not)/ Malignant
Patient was apparently asymptomatic __ days back when he developed
Inflammatory/Traumatic/Neoplastic/Congetital?
1. Swelling- Onset, site, duration, progression (of size), any H/O of rapid
Clinical: TB Cervical lymphadenitis?
size increase, any other associated swelling, any seoncdary changes
NOTES:
(Ulcer, satellite nodules, sinus, discharge), Pain associated with swelling
Levels of Neck Lymph Nodes:
(Alcohol) [duration, site, character, relation with swelling], if multiple
Level I - Submaxillary and submental
swellings ask in detail which came first to last, any associated fever, night
Level II - Upper jugular
sweats [Pel Ebstein, evening rise], Any loss of appetite, significant loss of
Level III - Middle jugular
weight, pressure effects due to swelling
Level IV - Lower jugular
Other sites of metastasis:
Level V - Posterior triangle
H/O Cough, haemoptysis, chest pain
Level VI - Central neck nodes
H/O abdominal pain, jaundice, abdominal distention
Level VII - Anterior mediastinal
H/O pain in end of long bones, back ache
H/O headache, vomitings, convulsions
PAST HISTORY:
H/O similar complaints
-Any H/O HTN, DM, CAD , Hypo/Hyperthyroidism/ Epilepsy/
Asthma/COPD/ / Blood transfusions
H/O irradiation to neck, syphilis, cancer, TB
Drug and Treatment History + Allergic History:

FAMILY HISTORY:
None of the patient’s parents, siblings or first degree relatives have or have had
similar complaints or any significant co morbidities VIRCHOW’S NODE: The left supraclavicular lymph node lying
H/O Lymphomas, TB history contact. between the two heads of sternocleidomastoid is called the
PERSONAL HISTORY: Virchow’s lymph node. This lymph node may be involved by
Diet, Appetite, Bowel, Bladder, Sleep, Addictions (Alcohol and Smoking), metastasis from carcinoma stomach, testicular tumour,
carcinoma oesophagus and bronchogenic carcinoma
PHYSICAL EXAMINATION
Differential Diagnosis:
1. GENERAL SURVEY
Chronic pyogenic lymphadenitis, Tubercular cervical
- General assessment of Illness- ECOG (Zubroad scale)/Karnofsky score)
lymphadenitis, Metastatic cervical lymph node, Hodgkin’s
-Mental state and intelligence (CCC)
lymphoma, Chronic lymphatic leukaemia
-Build, state of nutrition [weight loss and cachexia]
Pathological changes in tubercular lymphadenitis:
-Decubitus and Attitude, Any facies
Stage I: Stage of inflammation: There is solid enlargement of
A __ year old patient, supine decubitus who is __ built __ nourished is
the affected lymph node.
conscious, coherent, cooperative, and comfortably seated/lying on the
Stage II: Stage of abscess formation:
bed, well oriented to time, place and person.
Stage III: Stage of collar stud abscess
There is No Pallor, Icterus, cyanosis, koilonychias, generalised
Stage IV: Stage of sinus formation
lymphadenopathy and no pedal edema.
Depending on the location of the lymph nodes in relation to
VITALS: Temperature: Pulse, RR, BP.
the investing layer of deep cervical fascia the cervical lymph
LOCAL EXAMINATION-Thyroid nodes may be:
Superficial: Lymph nodes lying superficial to the investing
After taking informed consent, patient is examined by exposure of the layer of the deep cervical fascia
neck region. Deep: Lymph nodes lying deep to the investing layer of deep
INSPECTION: cervical fascia
1. Swellings: Number, Position, size, surface, margins and extent Palpation of Cervical lymph nodes:
2. Skin over swelling: condition, sinuses, ulcers etc. The cervical lymph nodes may be palpated both from front
3. Pressure effects: edema, facial swelling, respiratory distress. and the back the clinician stands behind the patient. The
neck is slightly flexed and turned to the side of examination.
PALPITATION:
The different groups of lymph nodes levels 1 to 7 are then
Confirm inspection findings
palpated systematically with one hand.
- Local rise of Temperature - Skin tenderness (local tenderness)
Level 1A are palpated at the submental triangle with the pulp
- SWELLINGS: Number, Site size, surface, margins, consistency,
of the fingers directed upwards with the neck slightly flex and
fluctuation, matted or not and fixity
turned to the same side.
DRAINAGE AREAS: Scalp, Face, Ears, Lips, Cheek, Tongue, Oropharynx,
Level 1B are palpated at the submandibular triangle.
floor of mouth, Parotid, Submandibular, Thyroid gland.
OTHER LYMPH NODE SITES: Axilla, Epitrochlear, Inguinal, Popliteal.
Level 2, 3, 4 are palpated along the line of internal jugular vein with the
pulp of the fingers
Level 5 nodes are palpated at the posterior triangle with the pulp of
the fingers
The supraclavicular nodes (Level 5) are palpated with the pulp of the
fingers kept at the supraclavicular fossa and asking the patient to shrug
the shoulder up
Level 6 nodes are palpated at the pre- and para-laryngeal and tracheal
region
 Thyroid Swelling CASE PROFORMA
LOCAL EXAMINATION-Thyroid
Name: Age: Sex: Occupation: Address:
After taking informed consent, patient is examined by
HISTORY exposure of both limbs up till mid-thigh
INSPECTION:
Chief Complaints:
-Position and extent of swelling -Shape of swelling, -Size of
Swelling in front of neck since
swelling, -Surface, - Margins, - Skin over swelling, Any
Pain in swelling since
pulsations, Movement with deglutition/protrusion of tongue
Hoarseness of voice since
-Lower border seen or not, -Any other swelling in neck,
Difficulty in swallowing since
visible pulsations, ulcer, sinuses, scars.
Difficulty in breathing since
Pizzilo method= inspect with hands behind the head and
Tremors/Palpitations since
patient is asked to push head backwards against clasped
History of Present Illness:
hands.
Patient was apparently asymptomatic __ days back when he
Pemberton’s sign= Raise both arms till they touch the ears.
developed
Keep it like that. Congestion of face and distress in case of
1. Swelling- Onset, duration, rate of growth, any associated pain
obstruction of great veins at thoracic inlet.
(sudden increase), any associated insomnia, anxiety, palpitations,
Trial’s sign: prominence of sternocleidomastoid on the side
(sleepless nights)
of deviation of trachea.
2. Pain- site, onset, duration, character, radiation, aggravated and
PALPITATION:
relieving factors
Confirm inspection findings
3.Pressure Symptoms- Difficulty in swallowing (Solid/liquid/both),
- Local rise of Temperature - Skin tenderness (local
difficulty in breathing, change in voice
tenderness)
Hyperthyroid symptoms: Increased appetite, loss of weight,
- Swelling: Site, size, surface( smooth=colloid, graves) shape,
diarrhoea, chest pain, palpitation, amenorrhoea, irritability,
margins, extent, consistency (soft=colloid/graves,
anxiety, tremors, insomnia, increased sweating, preference to
Firm=Solitary/multnodular goitre, Hard= carcinoma/reidel’s
cold (Heat intolerance), any proximal muscle weakness, bulging of
thyroiditis) , mobility of swelling (restricted in malignancy
eyes
and chronic thyroiditis), pulsation, thrill, skin fixity
Hypothyroid symptoms- weakness, lethargy, weight gain, poor
Lahey’s Method=To palpate right lobe push the right lobe
appetite, facial puffiness, cold intolerance, menorrhagia,
with right hand to right side and palpate with left hand
constipation, loss of hair (eyebrows), dry skin
Crile’s Method=Place the thumb on the thyroid while the
PAST HISTORY: patient swallows; this method is used to diagnose doubtful
H/O similar complaints nodules
-Any H/O HTN, DM, CAD ,TB, Hypo/Hyperthyroidism/ Epilepsy/ -To get below thyroid swelling
Asthma/COPD/ / Blood transfusions -Pressure Effects=
H/O irradiation to neck 1. Kocher’s test [Slight push on lateral lobes will produce
Drug and Treatment History: H/O Ant thyroid drug intake stridor in case of obstructed trachea]
2. Carotid Pulsation
FAMILY HISTORY:
3. Horner Syndrome [Anhidrosis, Ptosis, Miosis,
None of the patient’s parents, siblings or first degree relatives have or
have had similar complaints or any significant co morbidities Enopthalmos]
H/0 similar complaints in neighbours 4. Pemberton Sign
5. Position of Trachea
Obstetric and Menstrual History= H/O any abnormalities - Examination of cervical lymph nodes
PERCUSSION: Manubrium sterni (to rule out retrosternal
PERSONAL HISTORY: [Important] extension)
Diet (brassica family-low iodine), Appetite, Bowel, Bladder, Sleep, AUSCULTATION: Bruit over swelling (Upper pole) in
Addictions (Alcohol and Smoking), thyrotoxicosis
Any Allergies MEASUREMENT: Of neck at most prominent swelling
EXAMNIATION OF TOXIC SIGNS: Tremors, Eye Signs
PHYSICAL EXAMINATION
OTHER SYSTEMS:
1. GENERAL SURVEY
CVS- Normal S1 S2 heard, No murmurs.
- General assessment of Illness- ECOG (Zubroad scale)/Karnofsky
Respiratory: Normal vesicular breath sounds, No
score)
adventitious sounds, GIT- Per Abdomen
-Mental state and intelligence (CCC)
CNS- No Facial asymmetry, all reflexes are normal
-Build, state of nutrition
PROVISIONAL DIAGNOSIS:
-Decubitus and Attitude, Any facies
This is a case of diffuse/right/left sided swelling of the
A __ year old patient, supine decubitus who is __ built __
thyroid gland most probably a solitary thyroid
nourished is conscious, coherent, cooperative, and comfortably
nodule/multinodular goitre/colloid goitre. And functionally
seated/lying on the bed, well oriented to time, place and person.
eu/hyper/hypo thyroid with no evidence of pressure
There is No Pallor, Icterus, cyanosis, koilonychias, generalised
symptoms or signs of hyper/hypothyroidism.
lymphadenopathy and no pedal edema.
Benign/Malignant.
VITALS: Temperature: Pulse, RR, BP. [Sleeping pulse rate]
NOTES:
Berry’s sign: Malignant thyroid engulfs the carotid sheath
completely hence pulsation not felt on same side of swelling

Levels of Neck Lymph Nodes:

Level I - Submaxillary and submental
Level II - Upper jugular
Level III - Middle jugular
Level IV - Lower jugular
Level V - Posterior triangle
Level VI - Central neck nodes
Level VII - Anterior mediastinal

Eye Signs:
Exophthalmos: forward bulging of the eyeball
Stellwag’s sign (First sign) - Starring look with infrequent
blinking and wide palpebral fissures.

von Graefe’s sign - Lid lag sign. Tested by asking the patient
to look up and down many times fixing the head, you can
see the upper lid lags behind.

Joffroy’s sign - Absence of wrinkling of forehead. The

patientnlooks the roof of the room without forehead
wrinkling.

Dalrymple’s - Visible upper sclera due to lid retraction.

MÖbius sign - Inability to converge the eyeball.

Jellinek’s sign - Increased pigmentation of eyelids.

Thyroid profile:
Serum TSH - 0.5 to 5 micro units/ml
Total T4 - 50 to 150 nanomol/liter
Total T3 - 1.5 to 3.5 nanomol/liter
Free T4 - 12 to 28 picomol/liter
Free T3 - 3 to 9 picomol/liter
Thyroglobulin - <1 to 35 micrograms/liter

HIMALAYAN GOITRE BELT

It refers to the area of northern India extending 2400 km
from Kashmir in the west to Naga hills in the east where
goitre is endemic. It is the largest goitre belt in the world.
The following states are included in the Himalayan Goitre
Belt: Jammu and Kashmir, Himachal Pradesh, Delhi, Punjab,
Haryana, Uttar Pradesh, Bihar, West Bengal, Sikkim,
Arunachal Pradesh, Assam, Mizoram, Nagaland, Manipur,
Meghalaya, and Tripura
 VARICOSE VEINS CASE PROFORMA After taking informed consent, patient is examined in
standing
Name: Age: Sex: Occupation: Address: INSPECTION:
HISTORY -Assess Great (medial) and Short saphenous (lateral) veins,
popliteal swellings
Chief Complaints: -Look for (redness)superficial thrombophlebitis/generalized
Swelling along veins in Rt/Lt leg since swelling of DVT
Pain in Rt/Lf/both limbs since -Skin of Limb: 1. Colour, 2. Texture: Stretched/shiny due to
Pigmentation of skin of leg since edema, eczema/pigmentation (Gaiter area), ulceration
Ulcer in the leg since (examine like ulcer), scar of operations of varicose or healed
venous ulcer, toes-loss of hair/increased brittleness
History of Present Illness: -Cough Impulse (Saphenavarix)
Patient was apparently asymptomatic __ days back when he -Any ankle flares/venous stars
developed PALPITATION:
1. Swelling- site[Greater saphenous/Short saphenous], onset, Confirm inspection findings
duration, progression, relation to standing/walking, reduces on 1. Skin Temperature
lying down, any pain or color change along vein course 2. Skin tenderness (local tenderness)
2. Pain: onset, character, severity, time of occurrence (towards 3. Brodie Trendelenberg Test 1 and 2
end of day), Aggravating and relieving factors, any night cramps 4. Multiple Tourniquet test [Oschner Mahoner Test]=
3. Ulceration: Site, onset (traumatic, spontaneous), pain in ulcer, 5. Modified Perthes Test= to find deep vein thrombosis
discharge/bleeding, progression. • Important preliminary to do this test is that there should not be any
H/O itching, change in colour of limb perforator incompetence to do this test. Tourniquet is applied below
H/O constipation the saphenofemoral junction (no need to milk the veins before
applying tourniquet). • Ask the patient to walk with tourniquet
H/O lump abdomen
Observation:
H/O trauma
• Shrinking of varicose veins: Indicates that there is normal deep
H/O bladder symptoms (BPH) veins and perforators.
(Note: If there is perforator incompetence there will not be shrinking
of veins, hence cannot be done in cases of perforator incompetence)
PAST HISTORY: • More prominence of varicose veins associated with severe cramp
H/O similar complaints in the past like pain: Indicates there is deep vein thrombosis.
-Any H/O HTN, DM, CAD ,TB, Hypo/Hyperthyroidism/ Epilepsy/ Note: Advantage over Perthes is that here the result is objective
Asthma/COPD/ / Blood transfusions (veins becoming prominent) as well as subjective (cramp like pain).
Any H/O of prolonged immobilisation 6. Schwartze Test= Ask the patient to stand and keep thumb of one hand at
Drug and Treatment History: Previous surgeries, stockings use the saphenous opening. Tap with other hand along the course of long
saphenous vein in the lower part of leg. Impulse is felt in the thumb at
FAMILY HISTORY: saphenous opening. This test implies the valves along the GSV are
None of the patient’s parents, siblings or first degree relatives have or incompetent.
have had similar complaints or any significant co morbidities 7. Pratt’s Test= To mark the position of weak perforators. Steps:
• Apply Esmarch elastic bandage from toes to groin to empty the
superficial veins. • Apply tourniquet at groin (below SF junction). •
Obstetric and Menstrual History= H/O recurrent abortions
With tourniquet in position remove bandage gradually from above
PERSONAL HISTORY: below and simultaneously apply another elastic bandage from groin
Diet, Appetite, Bowel, Bladder, Sleep, Addictions (Alcohol and to toes in reverse direction. Inference: At the position of weak
perforators blow outs can be seen. Mark these blow outs with skin
Smoking), OCP use. In pregnancy- White leg
pencil.
Any Allergies
8. Morrisey’s Test= Limb is elevated to empty the veins and the limb is then
put to bed and the patient is asked to cough forcible. An expansile impulse is
PHYSICAL EXAMINATION
felt at the saphenofemoral junction in cases of sapheno-femoral
1. GENERAL SURVEY incompetence. Bruit can be heard on auscultation
- General assessment of Illness- ECOG (Zubroad scale)/Karnofsky 9. Fegan’s Test= after marking the blow outs make the patient lie
score) down to empty the veins. You can palpate the defect in deep fascia at
-Mental state and intelligence (CCC) these spots
-Build, state of nutrition 10. Oedema/Thickening/Redness (Periostitis)/ Lipodermatosclerosis
-Decubitus and Attitude, Any facies 11. Pulses-Arterial
12. Ian Aird Test= empty the proximal segment of the GSV with two fingers.
Release the proximal finger. If the vein fills up, it indicates SFJ incompetence.
A __ year old patient, supine decubitus who is __ built __
13. Homan’s Test = Forcible dorsiflexion of foot with knee extension causes
nourished is conscious, coherent, cooperative, and comfortably
pain in the calf.
seated/lying on the bed, well oriented to time, place and 14. Moses Test= Squeezing the calf muscles from side-to-side results in
person. severe pain at the calf.

PERCUSSION: Schwartz test

Check Pallor, Icterus, cyanosis, koilonychias, generalised
lymphadenopathy and pedal edema. AUSCULTATION: Along major arteries (Any bruit, systolic murmur,
VITALS: Temperature, Pulse, RR, BP. machinery murmur
Regional Lymph nodes: Inguinal (enlarged in venous ulcer)
LOCAL EXAMINATION-Varicose
 OTHER LIMB: Saphenous opening:
•• Just 4 cm below and lateral to the public tubercle
OTHER SYSTEMS: •• Closed by cribriform fascia and forms the lower boundary
CVS- Normal S1 S2 heard, No murmurs. of femoral canal
Respiratory: Normal vesicular breath sounds, No adventitious •• Saphenofemoral junction is seen just above the saphenous
sounds GIT: Per Abdomen Soft. opening
CNS- No Facial asymmetry, all reflexes are normal
II. Multiple tourniquets test
PROVISIONAL DIAGNOSIS: Step 1: Patient in recumbent position Milk all the veins. Three
This is a case of varicose vein affecting GSV of Rt lower limb with tourniquets are applied:
perforator incompetence of SFJ, below knee perforator and 5cm 1. Just below saphenofemoral junction 2. Just below mid-thigh
ankle perforator without any clinical evidence of DVT. 3. Just below knee
As per CEAP- C4as, Ep, Asp, Pr • Tourniquets are applied below each perforator.• Ask the patient
to stand.
NOTES Inference
CEAP Classification • Appearance of veins between tourniquet 1 and 2 is seen in
Clinical [S=Symptomatic pain, tightness, skin irritation, heaviness, adductor canal perforator incompetence • Appearance of veins
and muscle cramps, and other complaints attributable to venous between tourniquet 2 and 3 is seen in below knee perforator
dysfunction, A=Asymptomatic] incompetence • Appearance of veins below the 3rd tourniquet is
seen in lower leg perforators incompetent.
C0 No visible or palpable signs of venous disease If the veins above the tourniquet fills up and those below it remain
C1 Telangiectasies or reticular veins collapsed, it indicates presence of incompetent communicating
C2 Varicose veins vein above the tourniquet. Similarly if the veins below the
C3 Edema
tourniquet fill rapidly whereas the veins above the tourniquet
C4A Pigmentation or eczema
remain empty, the incompetent communicating veins must be
C4B Lipodermatosclerosis or athrophie blanche
below the tourniquet
C5 Healed venous ulcer
•• On releasing the tourniquet one by one from below upwards,
C6 Active venous ulcer
sudden retrograde filling of veins occurs. •• Some of them use a
.
fourth tourniquet palm breath above medial malleolus; appearance
Etiological Anatomical Pathophysiology of veins below 4th tourniquet implies lower leg perforator
incompetence
Ec: congenital As: superficial veins Pr: reflux Syndromes associated with varicose veins:
Ep: primary Ap: perforating veins Po: obstruction 1. Klippel-Trenaunay syndrome:
• Abnormal lateral venous complex (short saphenous)
Es: secondary Ad: deep veins Pr,o: reflux and obstruction • Capillary nevus• Bony abnormalities • Aplasia of deep veins •
Limb lengthening
En: no venous cause An: no venous location Pn: no venous pathophysiology
identified identified identifiable 2. Kasabach-Merritt syndrome: ‘Platelet trapping within
hemangiomas’
Signs of Gangrene: • Multiple cutaneous and large visceral hemangiomas
Change of colour(pale-bluish purple-black), Loss of temperature, Loss • Arteriovenous shunt • Congestive cardiac failure • Skeletal
of sensation, Loss of pulsation, Loss of function distortion and contour abnormalities • Hypopigmentation
Complications of Varicose Veins:
Perthes test Marjolin Ulcer, Periostitis tibia, Equinus deformity (Due to ulcer)
– Wrap the whole lower limb with elastic bandage Hemorrhage, Phlebitis, Calcification (Due to varicosity)
– Ask the patient to walk or exercise. Eczema, Pigmentation, Lipodermatsclerosis (Skin)
Result: If there is deep vein thrombosis, all the blood on getting diverted
into the deep venous system due to collapse of superficial venous system Varicose ulcers are treated by ‘Bissgard’s method: 4E’s=
by elastic bandage causes the deep venous system to dilate and results in Education, Elevation, Elastic Stockings, Exercise
severe cramps. Phlegmasia alba dolens (white leg)
The result is patient dependent and it is hence subjective Phlegmasia cerulea dolens (cyanotic mottled skin)
(Pregangrenous)
Brodie Trendelenburg test: Primary Varicose Veins= Idiopathic
Test 1. For saphenofemoral incompetence, Test 2. For perforator Secondary= 1. Obstruction to venous flow= Pregnancy,
incompetence Ovarioan mass, Pelvic organ cancer, Abdominal
Patient in recumbent position legs raised to empty the vein, may be lymphadenopathy, Ascites, Iliac vein thrombosis,
hastened by milking the veins. Tourniquet is applied below Retroperitoneal Fibrosis
saphenofemoral (SF) junction (Thumb may be used to occlude the SF 2. Destruction of Valve: DVT, OCP 3. High Pressure flow: AV
junction). fistula
Test 1: • Pressure released at the SF junction.• Varices fill very quickly from
above• Test 1 is positive, i.e. saphenofemoral incompetence is present.

Test 2: • Do not release the pressure for one minute • Gradual filling of
veins occur in the lower limb. • Test 2 is positive, i.e.
perforator incompetence is present.
 Examination of SCROTAL SWELLING GENERAL EXAMINATION:

Name: Age: Sex: Occupation: Address: Lungs- To exclude TB ( TB epididymo-orchitis), Malignancy of testis
mets
HISTORY Syphilitic stigmas (Gummamatous orchitis) {Alopecia, bossing of skull,
1. Age: Hydrocele is seen even in infants, but primary hydrocele is most interstitial keratitis, depression of nasal bridge, nasal septum
common over 40yrs. Secondary hydrocele common in 20-40 years. perforation, Hutchinson teeth, mucous patches, condylomas, otitis
2. Occupation: interna, enlarged occipital lymph nodes, Gummamatous orchitis,
Varicocele develops in men who work which require prolonged Clutton’s joints, Sabre tibia)
standing like bus conductor. Kidneys-TB epididymo-orchitis, varicocele
3. History of present illness: H/O Trauma- haematocele Rectal examination- Acute prostatitis precedes epididymo-orchitis.
LOCAL EXAMINATION-SCROTUM Seminal vesicles are enlarged and tender in tuberculous epididymitis.
A. INSPECTION:
1. Skin and Subcutaneous Tissue:
Normal scrotal skin is wrinkled and freely mobile over testis. Hydrocele
skin will be tense so normal rugosity of skin is lost and subcutaneous
veins are prominent.
2. Swelling: Hydrocele- small to very big, hanging till knee.
A peculiar constriction is often found around swelling. If hydrocele is
tense it tends to stand out (forward projection)
Note size, shape, extent of swelling. Does it extend up laong the
spermatic cord?
3. Impulse on coughing: Many times hydrocele is associated with
hernia- bubonocele or a complete inguinal hernia. Hernia shows
impulse on cough.

B. PALPITATION:
Swelling is purely scrotal is confirmed by getting above the swelling.
1. Skin: Any ulcer-describe it, fixity to testis (Gummamatous) or
epididymis (tuberculous)
2. Swelling: Temperature, tenderness, extent, size, shape, surface,
margins, consistency. Most common cystic swelling is a vaginal
hydrocele (collection of serous fluid in tunica vaginalis)
2 cardinal signs of HYDROCELE:
FLUCTUATION: Thumb and finger of one hand on lower pole push to
see separate thumb and finger of other hand at upper pole.
TRANSLUCENCY: A pencil torch is placed laterally and roll of paper
anteriorly. False Negative if testis comes in the way.
Uncomplicated hydrocele and cyst of epididymis are translucent.
Spermatocele is not translucent as fluid is not clear.
Reducibility of Swelling: Raise swelling and compress it.
Congenital hydrocele and varicocele are reducible. In former always
check ascites as it is associated with TB peritonitis.
Impulse on coughing: Root of scrotum is held, Expansile= hernia or
congenital hydrocele, Thrill like= varicocele or lymph varix.
3. Testis: Position, shape, size, surface (smooth or nodular),
Consistency, weight (compare by balancing testis on palm), Mobility,
testicular sensations.
4. Epididymis: Firm nodular structure attached to posterior aspect of
testis. Globus major (head), body, Globus minor (tail).
5. Spermatic Cord: Palpate at root of the scrotum between thumb and
index finger simultaneously on both sides.
Vas deferens felt as hard whip cord slipping between thumb and index
finger.
Lymph varix- soft and doughy, Varicocele- bag of worms
Both give thrill like impulse on cough but varicocele more readily
reduces.
6. Lymph Nodes: Skin of scrotum- inguinal lymph nodes,
Testis, Epididymis- Pre and Para aortic lymph nodes at level of origin of
testicular artery formation from Aorta. (trans pyloric plane)
Left Supraclavicular lymph node (malignancies)
 Examination of a lump or a swelling LOCAL EXAMINATION-SWELLING
A. INSPECTION:
Name: Age: Sex: Occupation: Address: 1. Situation: Dermoid seen in the midline of body or line of
A lump is a vague mass of body tissue. fusion of embryonic processes. Note extent in vertical and
A swelling is an enlargement or a protuberance in body due to horizontal direction.
congenital, traumatic, inflammatory, neoplastic or miscellaneous 2. Colour: Black: benign nevus, melanoma
causes. Red (arterial) or purple (venous) = hemangioma,
HISTORY Bluish colour = ranula.
1. Duration: 3. Shape: Ovoid/ pear shaped/ kidney shaped/ spherical/
When the lump was noticed? irregular
Shorter duration with pain =acute inflammation 4. Size: Vertical and horizontal dimensions.
with slight pain= possibly malignant 5. Surface: Cauliflower like- SCC, irregular numerous branched
Longer duration with pain= chronic inflammation surface of papilloma
without pain = benign 6. Edge: Clearly defined/distinct. Pedunculated/sessile.
2. Mode of onset: 7. Number: Single= Lipoma/ Dermoid. Multiple= NF, Diaphyseal
Noticed casually/following trauma/ developed spontaneously and aclasis
progressive increase in size = neoplasm/ from scar= keloid/ from 8. Pulsations: Aneurysm, vascular growths, carotid body
benign nevus or birth mark= melanoma tumour, arising from artery= Expansile pulsations
3. Other symptoms associated with swelling= pain, difficulty in Swelling lie superficial to artery= Transmitted pulsations.
respiration, swallowing, movements 9. Peristalsis: Visible peristalsis in intestinal obstruction, CHPS
4. Pain: 10. Movements with Respiration: Those arising from upper
Nature of pain- throbbing = inflammation leading to suppuration abdominal viscera move with respiration. Eg Liver, spleen,
burning/stabbing/distending/aching/ stomach, Gall bladder, splenic &hepatic flexures of transverse
Site-localized, referred colon.
Time of onset: pain before swelling = inflammatory 11. Impulse on coughing: Swellings in continuity with
swelling with pain = tumour [Except Osteosarcoma mild pain first abdominal cavity or pleural cavity, spinal canal or cranial cavity.
symptom precedes swelling] In children crying can work as coughing.
5. Progress of swelling: 12. Movement on deglutition: Swellings fixed to trachea or
Slow progressive or static= benign larynx. i. Thyroid swelling ii. Thyroglossal cyst iii Sub-hyoid
grows quickly= malignant transformation bursitis iv. Pre or Para tracheal Lymph Nodes.
decreases in size= inflammatory 13. Movement with protrusion of tongue: Thyroglossal cyst
6.Exact Site: Exact site from which swelling originated in case of connected by its thyroglossal tract
large swelling 14. Skin over swelling: Red, oedematous= Inflamed
7. Fever: suggests inflammatory swelling/abscess Tense, glossy with venous prominence= sarcoma with rapid
Pyogenic lymphadenitis/Hodgkin’s/ RCC growth
8. Presence of other lumps: Neurofibromatosis, Diaphaseal aclasis Presence of punctum= sebaceous cyst
has multiple. Hodgkin’s has multiple lymphoglandular enlargements. Pigmentation of skin=Moles, Naevi,
Abscess may occur one after other. Presence of scar= previous incision/injury.
9. Secondary changes: Softening, ulceration, fungation, inflammatory Peau D Orange= Carcinoma breast.
changes 15. Any Pressure Effects: Examine limb distal to swelling.
10. Impairment of Function: Any loss of movement in limb, spine Axillary swelling with edema of Upper limb= Lymph node
Osteosarcoma of knee causes partial or total loss of knee movements involved
Cold Abscess from caries spine limits spine movements Wasting of distal limb= Traumatic, Non Use, Nerve
11. Recurrence: If swelling recurred after removal involvement.
Eg: Paget’s, recurrent fibroid, cystic swelling with incomplete Neck swelling with venous engorgement: Retrosternal
removal extension of goitre.
12. Loss of body weight: Suggests malignancy or TB Skin and Subcutaneous tissue: Any visible swelling, engorged
13. Past History: Any similar swelling or recurrence. Past history of veins, any nodules
syphilis or TB.
14. Personal History: Habit of eating betel leaf, nut, slaked lime, B. PALPITATION:
tobacco for growth in mouth/tongue or cheek. 1. Temperature & Tenderness: Tender=inflamed,
Chutta cancer on hard palate is seen in women who smoke cigar with Non Tender =neoplastic
burnt end in mouth. Khaini cancer occurs due to mixture of lime and 2. Size, Shape, Extent: Vertical and Horizontal dimensions in cm.
tobacco kept in gingivolabial sulcus. (If swelling disappears behind a bone mention)
15. Family History: TB, Von Recklinghausen disease, malignant 3. Surface: Smooth= Cyst,
tumors. Lobular with smooth bumps= Lipoma, Nodular= Mass of matted
lymph nodes, Variable, irregular, rough= Carcinoma
PHYSICAL EXAMINATION 4. Edge: Well defined- neoplastic, chronic inflamed
1. GENERAL SURVEY. ill-defined or indistinct margins= acute inflamed
- Cachexia? Malnutrition SLIP SIGN= +ve swelling doesn’t yield and slips- Lipoma
Abnormal attitude? Paralysis due to nerve compression, Raised -ve : swelling yields = Cyst
temp and pulse rate- inflammatory.
5. Consistency: Soft= Lipoma, Cystic= Cysts & Abscess, Firm= Fibroma,
Hard but yielding=Chondroma, Bony Hard= Osteoma, Stony hard=
Carcinoma, Gaseous swelling with crepitus= Gas gangrene, Variable
consistency=Malignancy,
Moulding on pressure= Sebaceous/Dermoid/Colonic swelling with
faecal mass,
Pits= Inflammatory oedematous
6. Fluctuation: If swelling has liquid or gas. +ve for cysts. False positive:
Lipoma, fibroma, myxoma, vascular sarcoma. (Soft swellings, not no
increase in pressure felt)
Paget’s test: small swelling fluctuation test done by pressing the centre.
Cysts are soft at centre, solid swelling are firm at centre.
7. Fluid Thrill: Use 3 fingers, tap with middle for small swellings
8. Translucency: -ve in sebaceous & dermoid.
+ve if clear fluid, serum, lymph, highly refractive fat.
9. Impulse on cough
10. Reducibility: Swelling reduces and ultimately disappears-feature of
hernia. Lymph, varix, varicocele, saphena varix, meningocele also
reduce partly.
11. Compressibility: Can be compressed but does not disappear
completely. Swelling immediately appears after pressure taken off.
Liquid filled vascular malformations, arterial, capillary, venous
haemangiomas and lymphangioma re compressible.
12. Pulsatility: Expansile- Two fingers raise and separate
Transmitted- fingers only raise. In abdomen transmitted pulsations
cease in knee elbow position.
13. Fixity to overlying skin: Fixed if attached to skin (Papilloma,
Epithelioma, Sebaceous cyst) Skin over swelling is not pinch able.
14. Relation to surrounding structures:
Tumours arising from subcutaneous tissue: Free from overlying skin
and underlying contracted muscle
If lipoma is pushed sideways puckering is seen due to adhesions
If arising from deep fascia: Not as mobile as above
If arising from muscle: moves when muscle is relaxed, doesn’t move
when muscle is contracted.
If incorporated in muscles: swelling diminishes when muscle is taut
If swelling lies deep to muscle it virtually disappears when muscle is
taut.
Sometimes if evident only when muscle is taut: tear in the muscle
Arise from bone= absolutely fixed

C. State of Regional Lymph Nodes: Draining LN, Rule out generalized

lymphadenopathy.
D. PERCUSSION: If gaseous content=resonant note
Hydatid thrill
E. AUSCULTATION: For all pulsatile swellings: Any bruit, Machinery
murmur heard in aneurysmal varix
F. MEASUREMENTS: Any wasting distal to swelling.
G. MOVEMENTS: Nearby joints for any impairment
H. Examination of Pressure Effects: i. Arterial pulses distally if weak or
not. ii. Nerve compression-paresis/paralysis, sensory disturbance
iii. Erosion of bone: seen in dermoid cyst on skull or aneurysms.
I. GENERAL EXAMINATION:
If malignant look for mets in Chest (consolidation/effusion), Liver,
Abdomen (Peritoneal mets), Spine, Pelvis, Trochanters of femur (bony
mets), Syphilitic stigmas and Lymph nodes.
 Examination of an ULCER 8. Whole Limb: Presence of varicose veins, DVT- varicose ulcer,
Neurological insufficiency- Trophic ulcer
Name: Age: Sex: Occupation: Address:

‘An ulcer is a break in the continuity of the covering epithelium i.e. B. PALPITATION:
skin or mucous membrane following either molecular death of 1. Tenderness:
surface epithelium or its traumatic removal.’ 2. Edge and Margin: Marked induration (hardness of edge) –carcinoma
Slight induration- any chronic ulcer
HISTORY 3. Base: same as edge and margin
1. Mode of onset: Traumatic/ Spontaneous/ Following swelling or 4. Depth: Check in mm, Trophic ulcer may be deep till bone
tumour/ over varicose veins or venous insufficiency/ over scar, 5. Bleeding: Malignant ulcer bleeds to touch.
burns (Marjolin) 6. Relation to deeper structures: Fixed to underlying structures,
2. Duration: Malignant ulcer fixes to deeper structures by infiltration.
Acute/Chronic, Incubation period: between exposure and onset of 7. Surrounding Skin: Temperature, tenderness, (inflamed)
ulcer. 3-4 days = chancroid (soft sore), 3-4 weeks = Hunterian chancre Mobility- fixed to deeper structures- malignant
(syphilis) Loss of motor or sensory-Nerve deficits
3. Pain: Painful= inflammatory Peripheral nerves for abnormal thickening, tenderness.
Painless= resulting from nerve disease (syphilis ulcers, trophic ulcers, Arteries (atherosclerotic, Raynaud’s, Buergers)
malignant BCC). Tuberculous ulcer is slightly painful. Veins: (varicose veins)
4. Discharge:
Nature of discharge: pus/blood/serum. C. Examination of Lymph Nodes:
5. Associated disease: Nervous diseases (tabes dorsalis, transverse Acute infmaled ulcer- enlarged, tender, acute lymphadenitis
myelitis, syringomelia, peripheral neuritis), TB, Syphilis, Nephritis, DM TB ulcer- Enlarged, matted, slightly tender
Hunterian chancre-discrete, frim, shotty.
PHYSICAL EXAMINATION Gummamatous and Rodent ulcer-not involved
1. GENERAL SURVEY. Malignant ulcer-stony hard, fixed to structures.
- Cachexia? Signs of Malnutrition
-General Atherosclerosis, Syphilis, TB. D. Examination of Vascular insufficiency:
Veins- Varicose Veins, DVT
LOCAL EXAMINATION-ULCER Arteries- Atherosclerosis, Raynaud’s, Buerger’s
A. INSPECTION:
1. Size and Shape: TB-oval but can coalesce to be irregular, Syphilis- E. Examination of Nerve Lesions:
circular but can become serpiginous, Varicose- vertically oval, Trophic ulcer- Repeated trauma with sensory deficit seen in Tabes
Carcinomatous ulcer- irregular dorsalis, transverse myelitis, peripheral neuritis.
2. Number
3. Position: Varicose ulcer- over medial malleolus, Rodent ulcer- upper
part of face, usually line joining angle of mouth to ear lobule near inner GENERAL EXAMINATION:
canthus of eye. TB- near lymphadenopathy (neck, axilla, groin)
Lupus vulgaris of TB-face, fingers, hands. Syphilitic stigma, TB, Atherosclerosis (Look for whole body)
Hunterian chancre/soft sores- Genitalia, Trophic Ulcer do nervous examination.
Gummamatous ulcer- Subcutaneous bones like tibia, sternum, skull
Perforating or trophic ulcer- Heel or ball of foot which carries maximum
weight of the body
Malignant Ulcer- more common on lips, tongue, breast, penis.
4. Edge: Spreading ulcer-edge is inflamed oedematous, Healing ulcer-
Inside centre-Red= granulation tissue, Periphery- blue- thin growing
epithelium, and a white core-due to fibrosis and scar.
5 common types of edge. i. Undermined Edge- TB
ii. Punched out edge-Gummamatous or deep trophic ulcer,
iii. Sloping edge= Healing ulcer.
Iv. Raised or Pearly white beaded edge-Invasive cellular disease
(BCC/Rodent ulcer)
v. Rolled out/Everted Edge- SCC
5. Floor: Healthy and healing- Red granulation tissue,
Slow healing ulcer-smooth and pale granulation ulcer,
Gummamatous ulcer- Wash leather slough,
Malignant Melanoma-Black mass
6. Discharge: Character, amount, smell. Healing Ulcer- scanty serous,
Inflamed spreading ulcer- purulent,
Malignant or TB- serosanguinous discharge
Infected with B pyocyanea- greenish
7. Surrounding area: Acutely inflamed-glossy red oedematous,
Varicose-eczematous and pigmented
Old TB- scar or wrinkling
Gynecology
 GYNECOLOGY CASE PROFORMA Drug and Treatment History: H/O previous surgery for breast
Marital History:
Name, Wife of, Age, Booked/Not Booked, Address, Education, Years of marriage, Consanguinity, Husband living with patient or
Occupation, Income, Marital Status, Years of Marriage, not, Contraception, Infertility
Literacy Status, Religion, Socioeconomic Status
HISTORY FAMILY HISTORY:
None of the patient’s parents, siblings or first degree relatives have or
Chief Complaints: have had similar complaints or any significant co morbidities.
-Mass per vagina since (Prolapse case) Any H/O twins, congenital anomalies.
-Profuse bleeding P/V (Fibroid/Ovarian cyst
-Pain, Swelling in the abdomen (Fibroid/ovarian cyst)
- Pressure symptoms like Breathlessness, swelling of feet,
PERSONAL HISTORY: [Important]
difficulty in micturition, constipation, loss of weight.
Diet, Appetite, Bowel, Bladder, Sleep, Addictions (Alcohol
-Feminizing or virilising symptoms like precocious puberty, excess
and Smoking), Any Allergies, BLOOD GROUP
hair growth, change in voice, change in body contour.
History of Present Illness: PHYSICAL EXAMINATION
Prolapse:
-Mental state and intelligence (CCC)
Patient was apparently asymptomatic ___ back then she noticed
-Build, state of nutrition
mass per vagina which was initially ____ size gradually
-Decubitus and Attitude, Any facies
progressive to reach present size.
Check Thyroid enlargement, Breast, spine and gait.
Reducible (or not) manually (or spontaneously) & increases in size
[A __ year old patient, supine decubitus who is __ built __
on lifting weights & coughing. Relieved by lying down.
nourished is conscious, coherent, cooperative, and
Inconvenience whole walking, daily activities.
comfortably seated/lying on the bed, well oriented to time,
H/O low back ache-Onset, duration, site and type, A&R factors (in
place and person]
prolapse pain is due to uterosacral strain, hence relieved after 8
There is No Pallor, Icterus, cyanosis, koilonychias,
hours of sleep)
generalised lymphadenopathy and no pedal edema.
[In PID constant back ache with anterior radiation)
VITALS: Temperature: Pulse, RR, BP.
No H/O any discharge PV ( duration, quantity, colour, consistency,
smell, pruritus, in relation to menses increased or decreased) LOCAL EXAMINATION-ABDOMEN
H/O difficulty in micturition on straining.
H/O lifting weights for 30 yrs. After taking informed consent, patient is in supine position
No H/O Chronic cough with arms by the side of her body.
No H/O wound on mass PV INSPECTION:
No H/O constipation, incomplete evacuation External Genitalia: Normal/atrophied, decreased pubic hair,
No H/O leaking of urine on coughing/laughing pad of hair on labia (decreased oestrogen)
No H/O irreducibility episodes Mass: Pin globular mass is seen at/outside the vaginal
No H/O fever with chills & rigor with burning micturition introitus. If seen outside, __ cm from introitus
No H/O frequency of micturition Rugosities: of vaginal wall obliterated or is it dry and scaly.
Sulci: present or obliterated (bladder and submeatal sulci)
Obstetric History: Cervix: By identifying external os and anterios/posterior lips.
GPALD, Gap between marriage and first child, and gap between Healthy /unhealthy-discaharge, Congestion, hypertrophied
successive children. [Pelvic floor weakened, no time for or not, pigmentation (keratinisation)
involution] Any ulceration. (Decubitus ulcer : site, size, shape, number,
Booked case or not. [Booked cases are usually advised pelvic floor sloughy non healing/healing, undetermined/
exercises, rest after puerperium] excavated/sloping edge
Trained or untrained home deliveries Any discharge from cervix.
Duration of labour- prolonged, obstructed, episiotomy, any Stress incontinence: Ask patient to cough and look for
perineal tears. dribbling [all above for prolapse]
Instrumental, vacuum, caesarean or normal delivery Distention, Skin noticed for striae gravidarum and linea
Full term, pre term or post-dated. albicans/nigra, Umbilicus, All quadrants move equally with
Weight of the baby- Big baby damages pelvic floor respiration, Previous Caesarean scars, any visible pulsations
or engorgement of veins, Hernial orifices (for mass
Menstrual History: Age of menarche, Duration of cycle, Bleeding abdomen)
– regular/ heavy/ less, Passage of clot, number of pregnancies, PALPITATION: Consent taken and then Fundal height (in
breast feeding, LCB, use of HRT/contraceptives weeks), Fundal grip (Soft, Non ballotable, Broad mass
probably podalic pole) , Lateral grip [Left side hard board
PAST HISTORY: like mass felt probably baby’s back & On right side multiple
Past Obstetric History with the outcome, and development history fetal parts felt], First Pelvic Grip [hard ballotable, mass
and immunization history of each child probably cephalic pole] Second Pelvic Grip.
-Any H/O HTN, DM, CAD ,TB, Hypo/Hyperthyroidism/ Epilepsy/ Per Vaginal Examination – NOT done
Asthma/COPD/ / Blood transfusions
Past Medical & Surgical History OTHER SYSTEMS:
CVS- Normal S1 S2 heard, No murmurs.
Respiratory: BLAE + Normal vesicular breath sounds, No
adventitious sounds
CNS- No Facial asymmetry, all reflexes are normal
PROVISIONAL DIAGNOSIS:
A 65 yr old post-menopausal women came with P3L3 with 3
degree uterine prolapse with cystocoele & enterocoele &
also poor pelvic floor tone

NOTES:
Pain at Menstruation:
Mid Cycle Pain= Ovulation
Premenstrual pain= PID
Menstrual pain= Fibroids
Post menstrual pain= pelvic adhesions, endometriosis (triple
dysmenorrhoea = pain before, during and after)

Evaluation of Pelvic Organ Prolapse:

Stage 0 Normal position for each respective site

Stage I Descent of the uterus to any point in the vagina
above the hymen
Stage II Descent of the uterus up till the hymen
Stage III Descent of the uterus halfway past the hymen
Stage IV Total eversion or procidentia

Normal: Cervix at ischial spine

1st Degree: Descent of cervix into vagina
2nd Degree: Descent of cervix up to introitus
3rd Degree: Descent of cervix out of introitus
4th Degree: Procidentia= Complete descent with eversion.

De Lancey levels of supports of uterus:

Level I (for proximal 1/3rd of vagina) Cardinal and the
uterosacral ligaments
Level II (for middle 1/3rd of vagina) Paravaginal fascia
Level III (for distal 1/3rd of vagina and the introitus) Levator
ani and perineal muscles

Prolapse Treatment options:

Young-nulliparous-want kids = Sling Operation
35-40yrs, family not complete= Fothergill’s repair
[Manchester]
35-40yrs, family complete= Fothergill+ Sterilization
>40yrs, fit for surgery= Vaginal hysterectomy with Pelvic
floor Repair
>40 yrs, not fit for surgery= Le Fort’s repair
OBSTETRICS
 Obstetrics CASE PROFORMA PHYSICAL EXAMINATION

Name, Wife of, Age, Booked/Not Booked, Address, Education, -Mental state and intelligence (CCC)
Occupation, Income, Marital Status, Years of Marriage, -Build, state of nutrition
Literacy Status, Religion, Socioeconomic Status -Decubitus and Attitude, Any facies
HISTORY Check Thyroid enlargement, Breast, spine and gait.
[A __ year old patient, supine decubitus who is __ built __
Chief Complaints: nourished is conscious, coherent, cooperative, and
-This lady was admitted for safe institutional delivery in view of comfortably seated/lying on the bed, well oriented to time,
previous CS (For Previous LSCS Case) place and person]
-Difficulty in breathing, palpitations, chest pain etc since (for heart There is No Pallor, Icterus, cyanosis, koilonychias,
disease complicating pregnancy) generalised lymphadenopathy and no pedal edema.
-This lady was admitted for safe institutional delivery in view of VITALS: Temperature: Pulse, RR, BP.
Increased Blood pressure (for PIH case)
-This lady was admitted for safe institutional delivery in view of LOCAL EXAMINATION-ABDOMEN
Twin pregnancy
After taking informed consent, patient is in supine position
-Breathless, palpitations, weakness, fatigue, edema (in case of
with arms by the side of her body.
Anaemia complicating pregnancy)
INSPECTION:
History of Present Illness:
Distention, Skin noticed for striae gravidarum and linea
Obstetric Formula
albicans/nigra, Umbilicus, All quadrants move equally with
LMP, EDD, Mode of conceiving
respiration, Previous Caesarean scars, any visible pulsations
If primi ask how many years after marriage
or engorgement of veins, Hernial orifices
UPT done at ________ in _____ months of amenorrhea and
confirmed with a scan at ____ gestational age.
PALPITATION: Consent taken and then Fundal height (in
First Trimester
weeks), Fundal grip (Soft, Non ballotable, Broad mass
Nausea, Vomiting, Morning Sickness, Discharge/Bleeding per
probably podalic pole) , Lateral grip [Left side hard board
vagina, Increased frequency of micturition, Burning micturition,
like mass felt probably baby’s back & On right side multiple
Pain abdomen, Fever with or without rashes, Tetanus Toxoid, Folic
fetal parts felt], First Pelvic Grip [hard ballotable, mass
Acid Tablets, Teratogenic drug usage, Scan – Dating scan and
probably cephalic pole] Second Pelvic Grip.
Nuchal Translucency scan, Exposure to X-Ray
AUSCULTATION: Along the spinoumblical line on the side of
Second Trimester
the spine
Time of onset of Quickening, Discharge/Bleeding per vagina,
Per Vaginal Examination – NOT done
Infections/ Fever/ Rashes, Folic acid and Iron Tablets, Pedal
Edema, Calcium Tablets, Tetanus Toxoid, TIFFA [Targeted imaging
OTHER SYSTEMS:
for foetal anomalies] scan,
CVS- Normal S1 S2 heard, No murmurs.
Third Trimester
Respiratory: BLAE + Normal vesicular breath sounds, No
Continued perception of quickening and its frequency, Discharge/
adventitious sounds
Bleeding per vagina, Burning micturition, Pedal edema, Folic acid,
CNS- No Facial asymmetry, all reflexes are normal
Iron, Calcium tablets, Frequency of Antenatal check-ups, Scans
PROVISIONAL DIAGNOSIS:
A 22 yr Old Primi with term gestation with fundal height
PAST HISTORY: corresponding with gestational age with Hypertension
Past Obstetric History with the outcome, and development history complicating pregnancy, With No signs of imminent
and immunization history of each child eclampsia
-Any H/O HTN, DM, CAD ,TB, Hypo/Hyperthyroidism/ Epilepsy/ A 25 yr old Pregnant women with G3P2L1 came with
Asthma/COPD/ / Blood transfusions uncomplicated breech presentation for safe institutional
Past Medical & Surgical History delivery

Drug and Treatment History: H/O previous surgery for breast NOTES:
Marital History:
Years of marriage, Consanguinity, Husband living with patient or
not, Contraception, Infertility

FAMILY HISTORY:
None of the patient’s parents, siblings or first degree relatives have or
have had similar complaints or any significant co morbidities.
Any H/O twins, congenital anomalies.

Menstrual History: Age of menarche, Duration of cycle, Bleeding

– regular/ heavy/ less, Passage of clot, number of pregnancies,
breast feeding, LCB, use of HRT/contraceptives

PERSONAL HISTORY: [Important]

Diet, Appetite, Bowel, Bladder, Sleep, Addictions (Alcohol and
Smoking), Any Allergies, BLOOD GROUP